EMERGENCY CONTACT FORM - School District of Philadelphia

[Pages:1]EH-4 (Rev. 7/08) Student ID

SCHOOL DISTRICT OF PHILADELPHIA

EMERGENCY CONTACT FORM

Student's Name

Sex

Grade

Rm.-Sec.-Bk.

Birth Date

School No.

Address

Apt. No.

Home Phone

Enter Child's Pennsylvania I.D. Number Name of Child's Doctor/Clinic Name of Child's Dentist/Clinic First Emergency Contact - Parent/Guardian

Does your child have health insurance? ___ Yes

___ No

Phone No. Phone No. Relationship to child

If Yes, check the appropriate health insurance below:

__ Aetna/US Health Care __ Health Partners __ Keystone Mercy __ Other___________________

__ Blue Cross __ AmeriChoice __ Keystone Health Plan East

Daytime Phone

Cell Phone

E-Mail

Second Emergency Contact (full name)

Third Emergency Contact (full name)

EH-4 (Rev. 7/08) Student ID

SCHOOL DISTRICT OF PHILADELPHIA

EMERGENCY CONTACT FORM

Student's Name

Sex

Grade

Rm.-Sec.-Bk.

Birth Date

School No.

Address

Apt. No.

Home Phone

Enter Child's Pennsylvania I.D. Number Name of Child's Doctor/Clinic Name of Child's Dentist/Clinic First Emergency Contact - Parent/Guardian

Does your child have health insurance? ___ Yes

___ No

Phone No. Phone No. Relationship to child

If Yes, check the appropriate health insurance below:

__ Aetna/US Health Care __ Health Partners __ Keystone Mercy __ Other___________________

__ Blue Cross __ AmeriChoice __ Keystone Health Plan East

Daytime Phone

Cell Phone

E-Mail

Second Emergency Contact (full name)

Third Emergency Contact (full name)

EH-4 (Rev. 7/08) Student ID

SCHOOL DISTRICT OF PHILADELPHIA

EMERGENCY CONTACT FORM

Student's Name

Sex

Grade

Rm.-Sec.-Bk.

Birth Date

School No.

Address

Apt. No.

Home Phone

Enter Child's Pennsylvania I.D. Number Name of Child's Doctor/Clinic Name of Child's Dentist/Clinic First Emergency Contact - Parent/Guardian

Does your child have health insurance? ___ Yes

___ No

Phone No. Phone No. Relationship to child

If Yes, check the appropriate health insurance below:

__ Aetna/US Health Care __ Health Partners __ Keystone Mercy __ Other___________________

__ Blue Cross __ AmeriChoice __ Keystone Health Plan East

Daytime Phone

Cell Phone

E-Mail

Second Emergency Contact (full name)

Third Emergency Contact (full name)

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