Emergency Contact Information

Items marked with an asterisk (*) are required.

Form Requirement(s)

Can upload: Student
Can upload: Parent
Can upload: Staff

Required for Athlete Overall Approval.
Parent Signature Required.
Staff Signature Required.
Use of the Previous Year Form is allowed as long as it is not expired.

Auto Approval: Auto-Approve enabled with the EXCEPTION of all Uploaded forms and History Forms with Yes answers.

EMERGENCY CARD

Section I : Student Information

* Student Name

NEW ADDRESS

* Student E-mail

* Student Cellular Telephone

* Primary Address

* Birth Date

* Grade

* Church membership/Affiliation

* School District

* Last school attended

Section II : Parent / Guardian Information

* Primary Parent/Guardian Name

* Address

* Primary Parent/Guardian E-mail

* Home Telephone

* Cellular Telephone

* Occupation

* Name of Employer

* Employer Address

* Work Telephone

* Secondary Parent/Guardian Name:

* Address

* Secondary Parent/Guardian E-mail

* Home Telephone

* Cellular Telephone

* Occupation

* Name of Employer

* Employer Address

* Work Telephone

Section III : Alternate Emergency Contact – Other than Parent

* Contact’s Name

* Relationship to Child:

* Contact’s E-mail

* Home Telephone

* Cellular Telephone

Section IV : Medical Information / Medical Release

In a medical emergency, we hereby authorize Notre Dame High School to seek emergency medical assistance for our child if we cannot be reached. (If present in the household, both parents must sign and date below.)

Please keep a copy of this form for your records. IMPORTANT: Please update the school immediately if any information changes. If medical issues are pertinent to extra curricular activity or sport, please alert Nurse in Main Office and coach.

* Doctor’s Name

* Telephone

* Insurance Company

* Hospital Preference

* Policy #

* Group #

List student’s known allergies

List student’s Medical conditions

List student’s current Medications

Signatures

Parent / Guardian

Print Name:

Signature:

Date:

My clicking on the Sign & Submit Form button below is my signature and indicates that to the best of my knowledge, my answers and information provided to the above questions are complete and correct. I understand that the information about my account that I have provided on this form may be used for analytical and research purposes anonymously (without any personally identifying information). I consent to the access and use of this data by Pennsylvania Interscholastic Athletic Association, the Notre Dame Sd, BigTeams, LLC.