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Student Registration and Emergency Card
Student Name*
First Last
Birth Date*
Month
Day
Year
Birth Place*
Sex*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Father's Name*
First Last
Business Phone/Cell*
Mother's Name*
First Last
Business Phone/Cell*
Email*
School Name*
School Grade*
Armenian Grade*
Health problem required possible emergency action*
for example diabetes, bee sting allergies, other (specify). Type "none" or N/A if there are no health problems.
I understand that emergency information is required by Education Code section 49408, and I will notify the school IMMEDIATELY of any changes. In case you are unable to reach me during any emergency, you or your agent are authorized to contact, release, and if necessary, transport my child to any of the following:
Name of Doctor*
First Last
Phone Number*
Name of adult relative, neighbor, friend in the local area*
First Last
Phone*
Signature*

Student Registration and Emergency Card