1 OUR LADY OF MOUNT CARMEL SCHOOL 6 - 7 EMERGENCY INFORMATION 201 201 IMPORTANT PLEASE PRINT CLEARLY – RETURN THIS FORM TO SCHOOL OFFICE BY 9/ 9 * 6 * -- /1 FAMILY NAME: _____________________________ HOME TEL. NO: ____________________ ADDRESS: _________________________________________________________________ List first and Last Names of all children enrolled and grades: _______________________________ ____ ______________________________ ____ ___ ____ ______________________________ ____ ____________________________ /GUARDIAN : _________________________________________ MOTHER NAME OCCUPATION/PLACE OF EMPLOYMENT: _________________________________________ Work Number: ______________________________________ _________ Cell Number: ________________________________________________ *EMAIL ADDRESS: print clearly _____________________________________________ /GUARDIAN FATHER NAME : __________________________________________ OCCUPATION/PLACE OF EMPLOYMENT: _________________________________________ Work Number: _______________________________________________ Cell Number: _________________________________________________ _______________________ ________________________ EMAIL ADDRESS: print clearly * In the event the above persons cannot be reached in an emergency , please provide the names of LOCAL relatives/close friends who can be called. All names listed below are ssal. (Please PRINT clearly and authorized to pick up in case of an emergency or early dismi include area codes with both home and cell phone numbers). NAME: 1) ___________________________________ (relationship to child) ______________ ( Home # : __________________________ Cell # __________________________ (2) ___________________________________ (relationship to child) _____________ _ Home #: ___________________________ Cell # __________________________ (3) ___________________________________ (relationship to child) _______________ Home #: ________ __________________ Cell # ___________________________ _____ MY CHILD/CHILDREN TAKE BUS - ( Bus District ___________________ and BUS # _______ __ ___MY CHILD/CHILDREN ARE CAR PICKUP --- PLEASE FILL OUT THE BACK OF THIS FORM ALSO ---
2 INFORMATION EMERGENCY MEDICAL CHILD’S PHYSICIAN: __________________________________________ Address: _______________________________________________________________ Telephone # _____________________________ Any Allergies? _________________________________________________ _______________ My child takes the following medications daily: ____________________________________________________________________________ In the event that my child has an accident or illness which indicates the need for emergency medical treatment, I understand that OUR LADY OF MOUNT CARMEL SCHOOL will call me immediately. If I cannot be reached, I give the school permission to have my child transported by ambulance to the nearest hospital. PARENT SIGNATURE: _______________________________________ ____ *OUR LADY OF MOUNT CARMEL SCHOOL FOLLOWS THE MIDDLETOWN CENTRAL SCHOOL . DISTRICT. IF MIDDLETOWN HAS A 2 OR 3 HOUR DELAY, MT. CARMEL DOES ALSO - **In case of an emergency requiring early dismissal from school, including any weather related early sch ool closing, please review your emergency plan (whether they are pickup or to take their bus home) with your child/children. On days of early dismissal due to an emergency or weather NO LATCH KEY WILL BE OFFERED . REMINDER : If you are in another district, for example – Pine Bush – and Pine bush buses are picking up their students early , your child ren will leave on the Pine bush buses when /child y arrive to pick up. This is the same for any bus child/ children from any di strict other than the Middletown that closes early due to impending weather. Again, we have to follow the – Middletown School District Middletown rarely has an early dismissal. Only the names listed on the front of this form are authorized to sign your child /child ren out of school in case of early dismissals or emergencies. (Anyone else who comes to school to pick up must provide picture ID – Driver’s License – for verification before child /child ren are released ). Early dismissal information will be sent via the automated telephone notification system – I.R.I.S. – AND THROUGH LOCAL RADIO STATIONS. Information can also be found on the internet at: www.mtcarmel schoolmiddletown.org . Closing/delays will also be on WHUD.COM Storm Center, WPDH.com, on the Middletown School District Website and TWC Channel 20.
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