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Emergency Card

Please complete the form below. The parent/guardian is responsible for keeping the school informed of updates or changes to the student's emergency information. The school shall be notified, in writing, of telephone or address changes within three (3) days of the occurence.  

Required fields marked *

Please attach verification of physical custody.
or drag it here.
School is authorized to share my phone number with the PTA. *
Check here if student will be riding the bus*

The adults listed below are authorized to pick up and care for the above-named student. The student may be released to others with a written authorization. 

If the school is unable to reach anyone on this card in an emergency or if a student is left unattended during non-school hours, the school will contact law enforcement or Child Protective Services. 

I have read this and understand my responsibility. 

Does your child have a medical 504 Plan and/or IEP Plan (past or present)?*
Does the student wear glasses or contact lenses?*
Does the student wear hearing aids or is the student diagnosed with hearing loss?*
Please select any condition below that apply to your child.
Select all that apply.
Does student have condition that limits participation in the classroom or during physical education?

In the event of an emergency, when a parent/guardian is unavailable, I authorize school personnel to make such arrangements for my child to receive medical hospital care, including necessary transportation, in accordance with their best judgement. I further authorize the physcian named below to undertake such care of child, as he/she considers necessary. In the event said physician is not available, I authorize such care and treatment to be performed by a licensed physician or surgeon. I understand that the parent or guardian is responsible for the cost of such emergency care. 

Does the student have health insurance?
Does the student have dental insurance?
If you do not have insurance, do you give A.C.E. Academy permission to share this information to help apply for health insurance for the child?