Emergency Form

St. Philip ECC Emergency Form

Thank you for registering at St. Philip ECC.

Please take a moment and fill out the emergency form below. 

STUDENT'S INFORMATION
Please complete this form prior to your child attending their first day of school.
Name
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Please complete the section below. If your child has a preferred "nick name" please add that after the complete spelling of his or her first name.
Nick Name
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Date of Birth //
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Sex
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Grade Entering in 19-20sy
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Medical Alert
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First Contact
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Name of person to call first
Relationship
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Phone Number to Call first -- ext
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Official School Email for Communication
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Previous School/ Daycare Attended
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Other Schools your Child is Attending
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Person (s) or Agency Having Legal Custody of Child other than Parents
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Mother's Name
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Mother's Marital Status
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Mother's Home Phone --
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Mother's Email address
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Mother's Home Address
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Mother Employed By
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Mother's Job Title
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Mother's Work Phone -- ext
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Father's Name
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Father's Marital Status
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Father's Home Phone --
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Father's Email Address
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Father's Home Address
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Father Employed By
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Father's Job Title
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Father's Work Phone -- ext
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Names of Siblings Living at Home
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Please list all siblings living in the home with the child.
Child's Physician
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Physician's Phone Number -- ext
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List any Allergies or Intolerance to food, medication, etc.
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Describe the action to be taken if an allergy, intolerance, etc. occurs
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Does your child have a medical condition we should know about?
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Does he or she require daily medication?
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1st: Emergency Contacts: In case parents or guardians are not available
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Please list two emergency contacts. One may be out of state but one must be in the state of Virginia
First Emergency Contact
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First Emergency Contact -- ext
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First Emergency Contact --
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2nd Emergency Contact
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2nd Emergency Contact
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2nd Emergency Contact -- ext
  •  
2nd Emergency Contact --
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Authorized Pick Up #1: Who is authorized to pick up your child?
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Please list parent name.
Authorized Pick Up #2: Who is authorized to pick up your child?
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Parents must be listed
Authorized Pick Up: Who is authorized to pick up your child?
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Please list Emergency Contact
Authorized Pick Up: Who is authorized to pick up your child?
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Please List Emergency Contact.
Authorized Pick Up: Who is authorized to pick up your child?
  •  
please list anyone else who might need to pick up your child
Authorized Pick Up: Who is authorized to pick up your child?
  •  
please list anyone else who might need to pick up your child
Authorized Pick Up: Who is authorized to pick up your child?
  •  
please list anyone else who might need to pick up your child
Person (s) NOT authorized to pick up my child from school.
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Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.
Parent or Guardian Agreement I agree to notify the school within 24 hours if my child or any member of my immediate household has developed a communicable disease. I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, my emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment, which a physician deems necessary fro the well-being of my child.
Parent or Guardian Agreement
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General Information
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Signature
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Please print your name below agreeing that all information is correct.
Date //
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Notice: All information requested on registration is required by the Department of Social Services under the 22 VAC 13-30-80. Code
Social Media Policy & Permission
Wavier information / Right to Object
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Social Media Policy
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Readers and patrons are welcome to comment. Discussion is encouraged, but proper etiquette must be followed. Obscenities, spam, bashing, bullying, verbal abuse, insults, link solicitations, repetitive or fraudulent comments, and off-topic comments will be removed. It may be decided that comments will require approval prior to publication. We reserve the right to block a user at any time across any social media platform.
Handbook Agreement
I have read the current copy of the Parent/ Student Handbook. In doing so, I acknowledge and agree to the policies contained therein, and will require my student/s to comply with the policies.
Name
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E-mail
  •  
Date //
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Online Signature
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PARENT / GUARDIAN CONTACT INFORMATION
This form is to be completed by the enrolling parent. The enrolling parent is with whom the student lives the majority of the school week and enrolled the student in the school.
Enrolling Parent
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Address
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Home Phone --
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Work Phone -- ext
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Cell Phone --
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Relationship
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