Emergency Data Card

Student's Last Name

Last

Email

Father/Guardian Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Company Name of Parent/Guardian (Father’s) Employer

Work Phone

Mother/Guardian Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Company Name of Parent/Guardian (Mother's) Employer

Work Phone

Student lives with

Either Parent/Guardian Military?

Please list name(s) of your child(ren) who attend St. Peter School:

Name	Grade

If your child(ren) has(have) an illness or accident, please list below the names and telephone numbers of friends and/or relatives who may authorize emergency care when we are unable to contact you.

Name

First Last

Relationship

Phone Number

Name

First Last

Relationship

Phone Number

List the names of the people to whom we are NOT permitted to release your child[ren]:

Parent/Guardian (Father’s) Signature

Parent/Guardian (Mother’s) Signature