Student Emergency Information Form &lt;div&gt; 2022 -2023&lt;/div&gt;

Number of St. Thomas Aquinas School Students ***** Preschool - Grade 8 REQUIRED Please fill out this field.
Child 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade 2022 - 2023 REQUIRED Preschool 3 year - 3 day or 5 day Preschool 4 year Half Day Preschool 4 year Full Day Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Please fill out this field.
- Please provide information pertinent to each child - Allergies, Eye Glasses, Contact Lenses, student requires medications at school, health issues
Child 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade 2022 - 2023 REQUIRED Preschool 3 year - 3 day or 5 day Preschool 4 year Half Day Preschool 4 year Full Day Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Please fill out this field.
- Please provide information pertinent to each child - Allergies, Eye Glasses, Contact Lenses, student requires medications at school, health issues
Child 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade 2022 - 2023 REQUIRED Preschool 3 year - 3 day or 5 day Preschool 4 year Half Day Preschool 4 year Full Day Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Please fill out this field.
- Please provide information pertinent to each child - Allergies, Eye Glasses, Contact Lenses, student requires medications at school, health issues
Child 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade 2022 - 2023 REQUIRED Preschool 3 year - 3 day or 5 day Preschool 4 year Half Day Preschool 4 year Full Day Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Please fill out this field.
- Please provide information pertinent to each child - Allergies, Eye Glasses, Contact Lenses, student requires medications at school, health issues
Child 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade 2022 - 2023 REQUIRED Preschool 3 year - 3 day or 5 day Preschool 4 year Half Day Preschool 4 year Full Day Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Please fill out this field.
- Please provide information pertinent to each child - Allergies, Eye Glasses, Contact Lenses, student requires medications at school, health issues

FAMILY MEDICAL INFORMATION

Physician Name REQUIRED Please fill out this field. Please enter valid data.

Physician Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Physician Phone Number REQUIRED Please fill out this field. Please enter a phone number.

HEALTH INSURANCE INFORMATION

Company Name REQUIRED Please fill out this field. Please enter valid data.

Group Number Please enter valid data.

Contract Number Please enter valid data.

PARENT / GUARDIAN CONTACT INFORMATION

MOTHER

First Name Please enter valid data.

Last Name Please enter valid data.
Day Phone Number Maximum 20 characters Please enter a phone number.
Email Please enter an email address.
Employer (if applicable) Please enter valid data.
Work Phone Number (if applicable) Maximum 20 characters Please enter a phone number.

FATHER

First Name Please enter valid data.

Last Name Please enter valid data.
Day Phone Number Maximum 20 characters Please enter a phone number.
Email Please enter an email address.
Employer (if applicable) Please enter valid data.
Work Phone Number (if applicable) Maximum 20 characters Please enter a phone number.

GUARDIAN - IF APPLICABLE

First Name Please enter valid data.

Last Name Please enter valid data.
Day Phone Number Maximum 20 characters Please enter a phone number.
Email Please enter an email address.
Employer (if applicable) Please enter valid data.
Work Phone Number (if applicable) Maximum 20 characters Please enter a phone number.

EMERGENCY CONTACTS & DISMISSAL CONTACTS

Please provide at least one (you may provide more) Emergency Contact/s when PARENTS might not be available during the day. List someone who agrees to care for your child if he/she becomes ill and you cannot be reached. Please use someone local.

DISMISSAL CONTACTS - Please check if you are NOT providing additional dismissal information MY CHILD MAY ONLY BE RELEASED TO ME - NO DISMISSAL CONTACTS ARE PROVIDED

1.

First Name Please enter valid data.

Last Name Please enter valid data.
Relationship to student/s Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
This person may be called if a parent is not available - Check all that apply Emergency Contact Dismissal Contact

2.

First Name Please enter valid data.

Last Name Please enter valid data.
Relationship to student/s Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
This person may be called if a parent is not available - Check all that apply Emergency Contact Dismissal Contact

3.

First Name Please enter valid data.

Last Name Please enter valid data.
Relationship to student/s Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
This person may be called if a parent is not available - Check all that apply Emergency Contact Dismissal Contact

EMERGENCY MEDICAL TREATMENT CONSENT

In case of emergency, I hereby give permission to transport my child to the nearest hospital/emergency center for emergency medical treatment. I will be contacted as soon as possible, at the telephone numbers I have provided on this form, and will be advised prior to any further treatment by the hospital or medical personel. I understand it is my responsibility to provide St. Thomas Aquinas School with current health care information and emergency contact information.
Please choose: REQUIRED I Agree to Emergency Medical Treatment for my child/children. I DO NOT Agree to Emergency Medical Treatment for my child/children. Please fill out this field.

PARENT PERMISSION FOR WALKING FIELD TRIP TO PATRIARCHE PARK

I give permission for my child/children to participate in a school sponsored walk across Alton Rd. to visit Patriarche Park. This activity will be under the guidance and supervision of employees of St. Thomas Aquinas School and may occur throughout the school year.
Walking Field Trip Permission REQUIRED I give permission for my child/children to participate in a walking field trip to Patriarche Park. I DO NOT give permission for my child/children to participate in a walking field trip to Patriarche Park. Please fill out this field.

MEDIA RELEASE

There may be occasions when images or words of your child will be used on the school website and/or outside publications (i.e. brochures, flyers, advertisements, social media, etc.)
Media Release Consent REQUIRED Yes, you may use an image or words of my child on the school website and/or outside publications No, I do not wish for my child's image or words to be used on the school website and/or outside publications. Please fill out this field.

ST. THOMAS AQUINAS SCHOOL - UNIFORM POLICY

The STA school uniform instills in each student a sense of belonging and loyalty to the Tartan family and promotes modesty and decorum in each student's personal attire.
Uniform Policy - Dress Code is available in the STA School Handbook PLEASE CHECK - My student and I have read the STA school uniform policy and will follow what is required by the DRESS CODE

SIGNATURE

*Both Parents Must Sign (if applicable)* I agree to accept the policies, rules and regulations of St. Thomas Aquinas School.
Agree Please select this field.
Parent or Guardian #1 REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.
Parent or Guardian #2 if applicable Please enter valid data.
Date Please enter a date.
Email REQUIRED Please fill out this field. Please enter an email address.

St. Thomas Aquinas Parish School

"The soul of education is the education of the soul" fr. mac

Student Emergency Information Form
2022 -2023

Student Emergency Information Form 2022 -2023

Student Emergency Information Form
2022 -2023