STUDENT EMERGANCY INFORMATION           


Child's Name:
Date of Birth:
Grade: Kindergarten 1st 2nd 3nd 4th 5th 6th N/A
In the box below, please list any allergies, Medical conditions, or special needs your child may require. Please be specific as every small piece of information will allow us to better handle your child's needs, both day to day and in an emergency situation.


If you do not have any additional kids to enter, skip down to the parent information section.

Child's Name:
Date of Birth:
Grade: Kindergarten 1st 2nd 3nd 4th 5th 6th N/A
In the box below, please list any allergies, Medical conditions, or special needs your child may require. Please be specific as every small piece of information will allow us to better handle your child's needs, both day to day and in an emergency situation.



If you do not have any additional kids to enter, skip down to the parent information section.

Child's Name:
Date of Birth:
Grade: Kindergarten 1st 2nd 3nd 4th 5th 6th N/A
In the box below, please list any allergies, Medical conditions, or special needs your child may require. Please be specific as every small piece of information will allow us to better handle your child's needs, both day to day and in an emergency situation.



If you do not have any additional kids to enter, skip down to the parent information section.

Child's Name:
Date of Birth:
Grade: Kindergarten 1st 2nd 3nd 4th 5th 6th N/A
In the box below, please list any allergies, Medical conditions, or special needs your child may require. Please be specific as every small piece of information will allow us to better handle your child's needs, both day to day and in an emergency situation.



If you do not have any additional kids to enter, skip down to the parent information section.

Child's Name:
Date of Birth:
Grade: Kindergarten 1st 2nd 3nd 4th 5th 6th N/A
In the box below, please list any allergies, Medical conditions, or special needs your child may require. Please be specific as every small piece of information will allow us to better handle your child's needs, both day to day and in an emergency situation.



If you do not have any additional kids to enter, skip down to the parent information section.

Child's Name:
Date of Birth:
Grade: Kindergarten 1st 2nd 3nd 4th 5th 6th N/A
In the box below, please list any allergies, Medical conditions, or special needs your child may require. Please be specific as every small piece of information will allow us to better handle your child's needs, both day to day and in an emergency situation.



If you do not have any additional kids to enter, skip down to the parent information section.

Child's Name:
Date of Birth:
Grade: Kindergarten 1st 2nd 3nd 4th 5th 6th N/A
In the box below, please list any allergies, Medical conditions, or special needs your child may require. Please be specific as every small piece of information will allow us to better handle your child's needs, both day to day and in an emergency situation.



Parent Information

Father's Name:
Father's Cell:
Father's email:

Mother's Name:
Mother's Cell:
Mother's email:

Home Phone:
Address:
City:
Zip:

In the box below, please list any additional adults who are authorized to pick up your children from class. Note: authorization here does not override the parent badge requirement.



Submission of this form constitutes a standard media release allowing Valley View Christian Church to use photographs, video, or quotes from any or all children listed in this form in any publication, media production, or web site sponsored or created by Valley View Christian Church.