The Rhoades School Online Emergency Card 2020-2021

One Online Emergency Card must be completed for each child. All students (returning and new) must have an updated Emergency Card. Your child(ren) will not be able to attend the first day of school until we have received a completed Emergency Card.

Student Information

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* Student First Name

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* Student Last Name

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* Student Date of Birth

Date / Time

Date

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* Grade Level (2020-2021)

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* Mailing Address

Address

City

State

Zipcode

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* If parents are living in separate households and would like duplicate academic records, please select "Yes". If parents live in the same household, please skip question.

Yes

Household 1 Contact Information

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* Household 1 Mailing Address (leave blank if same as student)

Address

City

State

Zipcode

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* Parent/Guardian 1

First Name

Last Name

Relationship to student

Cell Phone Number

Work Phone Number (if applicable)

Home Phone Number (if applicable)

Email Address

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* Parent/Guardian 1 - I would like to receive communication from The Rhoades School Foundation via email.

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* Parent/Guardian 1 - I would like my email included in the Grade Level Parent Email Directory.

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* Parent/Guardian 2

First Name

Last Name

Relationship to student

Cell Phone Number

Work Phone Number (if applicable)

Home Phone Number (if applicable)

Email Address

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* Parent/Guardian 2 - I would like to receive communication from The Rhoades School Foundation via email.

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* Parent/Guardian 2 - I would like my email included in the Grade Level Parent Email Directory.

Household 2 Contact Information (leave blank if not applicable)

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* Household 2 Mailing Address (leave blank if same as student)

Address

City

State

Zipcode

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* Parent/Guardian 1

First Name

Last Name

Relationship to student

Cell Phone Number

Work Phone Number (if applicable)

Home Phone Number (if applicable)

Email Address

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* Parent/Guardian 1 - I would like to receive communication from The Rhoades School Foundation via email.

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* Parent/Guardian 1 - I would like my email included in the Grade Level Parent Email Directory.

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* Parent/Guardian 2

First Name

Last Name

Relationship to student

Cell Phone Number

Work Phone Number (if applicable)

Home Phone Number (if applicable)

Email Address

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* Parent/Guardian 2 - I would like to receive communication from The Rhoades School Foundation via email.

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* Parent/Guardian 2 - I would like my email included in the Grade Level Parent Email Directory.

Emergency Contacts and Authorized Pick Up

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* Emergency Contact (NOT a parent/guardian)

First Name

Last Name

Relationship to student

Cell Phone Number

Email Address

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* Please list individuals who are authorized to pick up your child.

Vehicle Information (Optional)

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* Vehicle #1 Information (Optional)

Vehicle #1 Owner Name

Vehicle #1 Make

Vehicle #1 Model

Vehicle #1 Color

Vehicle #1 License Plate Number

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* Vehicle #2 Information (Optional)

Vehicle #2 Owner Name

Vehicle #2 Make

Vehicle #2 Model

Vehicle #2 Color

Vehicle #2 License Plate Number

Parent/Guardian Acknowledgement

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* I have read and accept the policies and procedures outlined in the 2020-2021 Family Handbook. You may view the Family Handbook here.

Type Initials Here

Student Health Information

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* Does your child have any allergies? If so, please specify below. Skip if not applicable.

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* Does your child have any food and/or anaphylaxis inducing allergies? If yes, you MUST provide a physician signed allergy action plan to the office prior to the start of school.

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* Has your child been prescribed an Epi-Pen?

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* Does your child have Asthma and/or use an inhaler? If so, you must provide a physician signed asthma action plan to the office prior to the start of school.

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* Date of Last Tetanus Shot

Date / Time

Date

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* Please list all chronic and pertinent medical conditions school officials should be aware of. Leave blank if not applicable.

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* In the event of an emergency requiring medical attention, I hereby grant permission to a physician or other hospital personnel designated by The Rhoades School to attend to my child. I expect every effort will be made to contact me and/or Parent/Guaridan 2 in order to receive specific authorization before any treatment or hospitalization is initiated.

Type Whole Name Here

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* Primary Care Physician Information

Physician Name

Phone Number

Address

City

Zipcode

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* Health Insurance Information

Group Medical Carrier

Group Medical Name

Group Medical #

Family/Individual Medical #

Medical Record #

Other Medical Info

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* Dentist Information

Dentist Name

Phone Number

Address

City

Zipcode

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* Dental Insurance Information

Group Dental Carrier

Group Dental Name

Group Dental #

Family/Individual Dental #

Dental Record #

Other Dental Info