Emergency Card

Today’s Date:

Office Use Only Custody Medical

Photo Y - N

Student Emergency Information Record
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Students Name: (Last name, First name) Sex Ethnicity Birth Date
______________________________________________________________________________

Address:_______________________________________________________________________
______________________________________________________________________________

City: State: Zip Code:
______________________________________________________________________________

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Parent / Guardian Home Number: Work Number: Cellular Number:
1._____________________________________________________________________________
2.______________________________________________________________________

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Other Students residing at the same address: ________________________________________________________________________________________________

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The school will only release your child to the people listed below:
Name: Relationship to student: Phone number:

Alternate Phone: 1.______________________________________________________________________________________________ 2.______________________________________________________________________________________________
3.______________________________________________________________________________________________
4.______________________________________________________________________________________________

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Health Alerts
________________________________________________________________________

Doctor’s note required if recess or physical education restrictions are needed.
MEDICAL RELEASE – In case of an accident or serious illness, I hereby authorize Trillium Academy to follow their emergency medical care procedures. The school will attempt to contact me. If the school is unable to reach me, or the emergency contact names listed above I hereby authorize Trillium Academy to make medical decisions related to my child, this includes calling 911. I agree to pay all expenses incurred by the emergency care provided.
Health information provided on this form and information submitted on physical health appraisals may be shared with school personnel who are involved with the health and safety of my child.

Physician’s Name: _____________________________________ Office Phone: ______________ Parent Signature: ______________________________________ Date: _____/______/______

*** PLEASE FILL OUT BOTH SIDES***

Please note any custody arrangements:
______________________________________________________________________

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Publication Consent: Trillium Academy utilizes social media to share the programs and experiences of our school community with you as parents as well as promoting high quality educational opportunities for our students. Our performances, student’s activities, and other educational experiences will be shared through our school social media including the website, Facebook, news, and social media, etc. Please understand that we ask your permission below to utilize photos that include your child in these publications. While we refrain from using photos highlight just all of our school performances, athletic events, and school events such as assemblies, etc. will be photographed and publicized. By allowing your child to participate in these programs you accept that your child will be included in those publications.

By signing below I acknowledge that I have read and understand the media release guidelines and
____ I do NOT give permission for my child to be highlighted as an individual in photo opportunities, but understand they may be included in group photo opportunities.
____ I give permission for my child to be highlighted as an individual in photo opportunities, and understand that they may also be included in group photo opportunities.

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Students That Drive To School

Yes No I give permission for my child to drive home from school when ill or for emergency purposes after a parent/guardian is contacted via phone from school office.
Yes No I give permission for my child to drive their siblings from school when ill or for emergency purposes after a parent/guardian is contacted via phone from school office.

If student has permission a parent/guardian must sign this section in front of school official.

Parent/Guardian Name: __________________________________ Date ____/_____/____ Parents E-mail address ____________________________________

Primary Language Used in the home__________________________

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