Emergency Contact Information

1.	Child's Name First Name / Last Name
	First Name   M.   Last Name

2.	Date of Birth
	mm/dd/yyyy

3.	Gender
	Gender Male  Female

4.	Grade
	--None--Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade

5.	Parent's/Guardian's Name First Name / Last Name
	First Name   Last Name

6.	Daytime Phone

7.	Evening Phone

8.	Address
	Address 1   Address 2   City   State   Zip Code

9.	Email Address

10.	Parent's/Guardian's Name First Name / Last Name
	First Name   Last Name

11.	Daytime Phone

12.	Evening Phone

13.	Address
	Address 1   Address 2   City   State   Zip Code

14.	Email Address