St. John's Prep
Emergency Contact Form
Student First Name*
Student Last Name*
Parent First and Last Name*
Parent Cell Phone*
Additional Emergency Contact Name*
Provide the name of person to contact in emergency if parent cannot be reached.
Cell Phone for Additional Emergency Contact*
Allergies and/or Medical Conditions*
Does the student have allergies or medical conditions hos/he teacher should be aware of?
If you answered yes, please explain.
If student carries an epi-pen, can they self-administer?