Student Emergency Contact Form 2015-16

Fannie C. Williams Charter School
11755 Dwyer Road
New Orleans, LA 70128
504.373.6228
Student Emergency Form 2014-2015

Student ______________________________________________________________________________
Last Name First Name Middle Name

Date of Birth __________________________________ Social Security No. __________________

Address ________________________________________________________________
Street # City/State Zip Code

Parent/Guardian _________________________________________________________
Last Name First Name

Relationship _____________________________________________________________

Telephone # _____________________________ Alternative # ____________________

Email Address ___________________________________________________________
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
In case of an emergency contact:

1. ______________________________________________________________________
Last Name First Name Relationship

Telephone # _______________________ Alternative #___________________________

2. ______________________________________________________________________
Last Name First Name Relationship

Telephone # _______________________ Alternative # ___________________________

3. ______________________________________________________________________
Last Name First Name Relationship

Telephone # ____________________ Alternative # ___________________________

My child walks home ____

My child is a car rider, and is picked up by ______________________________________

His/Her Cell # ______________________________________

My child rides school provided transportation–Bus # ______ and get on/off at ________________________________ & _________________________________.

Parent’s/Guardian’s Signature ________________________________________________

Teacher’s Name ______________________________________________________________________