Student Emergency Contact Form 2018-19

Fannie C. Williams Charter School
11755 Dwyer Road
New Orleans, LA 70128
504.373.6228
Student Emergency Form 2018-2019

Student’s Name ___________________________________________________________________________________
Last Name. First Name. Middle Name (please print legibly)

Date of Birth __________________________________ Grade _______ Teacher’s Name ____________________

Month/Day/Year

Address __________________________________________________________________________________________
#Street City State Zip Code

Parent/Guardian’s Name _______________________________________________________ Mr. Mrs. Ms. Dr.
Last Name First Name Circle One

Relationship _____________________________ (parent, guardian, grandparent, older sibling other?)

Telephone # (_______)_________________ Cell or Landline? Alternative # (________)___________________

Email Address __________________________________________________________________ (print legibly)
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
In case of an emergency contact and I can’t be reached call:

1. ______________________________________________________________________ Mr. Mrs. Ms. Dr.
Last Name First Name Relationship Circle One

Telephone # (______) _________________ Alternative #(________)___________________

2. ______________________________________________________________________ Mr. Mrs. Ms. Dr.
Last Name. First Name Relationship Circle One

Telephone # (_______) ________________ Alternative # (_________). __________________

3. ______________________________________________________________________
Last Name First Name Relationship

Telephone # (_______) _____________ Alternative # (_________). __________________

My child walks home ___ /My child is a car rider ___, picked up by _____________________________ Cell # (_____)___________

My child rides school provided transportation–Bus # ______ and gets on/off at _________________ & ______________________

Parent’s/Guardian’s Signature ________________________________________ Today’s Date ______/_______/20_____