Student Emergency Card

Student Name

Student Date of Birth

Student Social Security Number

Street Address

City

State

Zip Code

1st Guardian Name

Cell Phone

Place of Employment

Address of Employment

Work Phone

2nd Guardian Name

Cell Phone

Place of Employment

Address of Employment

Work Phone

In The Event Of An Emergency, Mount Olive Lutheran School Is Authorized To Obtain EMERGENCY MEDICAL Or DENTAL CARE Even If The School Is Unable To Immediately Make Contact With The Parent/Guardian.

Indicate yes or no

Date

Signature

Emergency Contact (not listed above)

Name

Phone

Relationship to child

Doctor Information

Name

Phone

Address

Dentist Information

Name

Phone

Address

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[field id="email_1st"]

[field id="cell_1st"]

[field id="employment_1st"]

[field id="work_phone_1st"]

[field id="2nd_guardian_name"]

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[field id="employment_2nd"]

[field id="work_phone_2nd"]

[field id="emergency_name"]

[field id="emergency_phone"]

[field id="relationship"]

[field id="doctor_name"]

[field id="doctor_phone"]

[field id="doctor_address"]

[field id="dentist_name"]

[field id="dentist_phone"]

[field id="dentist_address"]

[field id="yes_or_no"]

[field id="date"]