Student ID School Use Only Teacher

student id # ________________________ school use only teacher ____________________ enrollment date _____________________ grade _____________

Student ID # ________________________ School Use Only Teacher
____________________
Enrollment Date _____________________ Grade _____________
CECIL COUNTY PUBLIC SCHOOLS EMERGENCY INFORMATION CARD
SCHOOL YEAR ______________
--------------------------
It is the parent’s/guardian’s responsibility to keep this information
current.
NEW ENTRANT STUDENT DATA
========================
Student’s Legal Name:
Last Name First Name Middle Name
Other Name: (Name other than legal name by which the student is known
– DO NOT LIST NICKNAMES
Date of Birth: ______ Student’s School Bus Number
Student’s Primary Phone Number(s):
Student’s Home Address:
Street City State Zip
Mailing Address (if different from Home Address):
P.O.Box City State Zip
Day Care Provider’s Name:
Day Care Provider’s Address:
Day Care Provider’s Phone Number(s):
Brothers and Sisters: Name Date of Birth
RESPONSIBLE PARENT/GUARDIAN CONTACT INFORMATION
===============================================
Is there an existing court order regarding CUSTODY for the
above-mentioned student?
Yes  No  If yes, have you submitted a copy to the school? Yes  No 
Name of Parent/Legal Guardian with whom the student lives:
1.
_____________________________________________ Relationship to
child
Parent/Guardian Primary Phone # Secondary phone number
Employer Work phone number
2.
_____________________________________________ Relationship to
child
Parent/Guardian Primary Phone # Secondary phone number
Employer Work phone number
List persons—other than the parent/guardian listed above, that should
be contacted in case of an emergency during the school day and who are
permitted to take the student home (list in priority order).
Name Relationship to Student Phone Number
3
4
5
6
HEALTH/MEDICAL INFORMATION
This information will be shared with school teachers, staff, or
emergency personnel when we feel it is necessary.
Doctor’s Name Doctor’s Phone Number
Dentist’s Name Dentist’s Phone Number
Allergies (food, bee sting, medication, etc.)
Current medications taken at home and at school
Medical condition diagnosed by a doctor
Does your student have health insurance? Yes  No 
Parent/Guardian Signature _ Date __________ Rev. 02/17