Emergency Information

All fields below are required. Please place an N/A for not applicable if needed.

Student Information

Student First Name

Student Last Name

Program

Session

Grade

Address

City

State

Zip Code

Phone Number

Is this phone number unlisted?

Birthdate This information will not be given out. MM/DD/YYYY

Student Home E-mail address (not school email address)

Student resides with

Where parent/guardian can be reached if not at home:

Primary Parent/Guardian Name

Guardian Home Phone No.

Guardian Work Phone No.

Guardian Address

Guardian Cell Phone No.

Guardian E-Mail address most used

Send reports to this mailing address

Secondary Parent/Guardian Name

Guardian 2 Phone No.

Guardian 2 Work Phone No.

Guardian 2 Address

Guardian 2 E-Mail addressed most used

Guardian 2 Cell Phone No.

Send reports to this mailing address (Guardian 2)

Please indicate if you are:

Parent/Guardian Portion

I hereby grant permission for the above student to participate in district approved, class related field trips supervised by the instructor. Yes No

I hereby grant Eaton RESA Career Preparation Center, Lansing Community College, Davenport University, AIS Construction, Olivet College, Potter Park Zoo or Farm Bureau permission to photograph/videotape my child as they deem necessary for school use and/or media release. Yes No

I hereby grant permission for my student to be transported by an Eaton RESA staff member, when necessary. Yes No

In case of accident or serious illness, if the school is unable to reach me, I hereby authorize the school to call the physician indicated below and to follow instructions given. If it is impossible to contact this physician the school may make whatever arrangements deemed necessary. Please give emergency names other than parents.

Physician Name

Physician Phone No.

Emergency Contact Name A

Emergency Contact A Relationship

Emergency Contact A Home Phone No.

Emergency Contact A Work Phone No.

Emergency Contact Name B

Emergency Contact B Relationship

Emergency Contact B Home Phone No.

Emergency Contact B Work Phone No.

Allergies

Other Conditions

Medications Taken Daily

Signature Please write your legal name on this line in place of a signature.

Date MM/DD/YYYY

Eaton RESA does not discriminate on the basis of race, color, national origin, sex, (including sexual orientation and transgender identity) disability, age, religion, height, weight, marital or family status, military status, ancestry, genetic information, or any other legally protected category, (collectively, “Protected Classes”), in its programs and activities, including employment opportunities. In addition, arrangements can be made to ensure that the lack of English language proficiency is not a barrier to admission or participation. Civil Rights Coordinators are located at 1790 E. Packard Hwy, Charlotte Michigan to handle inquiries regarding the nondiscrimination policies and grievance procedures. Telephone (517) 543-5500.

Student Emergency Contact Information