Emergency Contact Form (blue card)

You can fill this form out in your NYC schools account, where you can also see your student grades, test scores, take classes in Parent University, Report bullying, Access forms for your child, Reset your child's DOE account password, Access SupportHub and more!

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Student Information

First Name*

Answer required for "First Name"

Middle Name

Answer required for "Middle Name"

Last Name*

Answer required for "Last Name"

Date of Birth*

Answer required for "Date of Birth"

OSIS Number*

Answer required for "OSIS Number"

Primary Guardian Information

This Guardian Can:*

Answer required for "This Guardian Can:"

Be contacted in emergencies

Pick up student

Receive School mailings

Guardian First and Last Name (Who the Student Resides With)*

Answer required for "Guardian First and Last Name (Who the Student Resides With)"

Relationship to Student*

Answer required for "Relationship to Student"

Preferred Language of Communication*

Answer required for "Preferred Language of Communication"

Home Phone*

Answer required for "Home Phone"

Mobile Phone*

Answer required for "Mobile Phone"

Ok to text*

Answer required for "Ok to text"

Yes

Work Phone

Answer required for "Work Phone"

Email Address*

Answer required for "Email Address"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Question

Number Required

Zip Code / Postal Code*

Answer required for "Zip Code / Postal Code"

Additional Guardian Information

This guardian can

Answer required for "This guardian can"

Be contacted in emergencies

Pick up student

Receive School Mailings

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Relationship to student

Answer required for "Relationship to student"

Email Address

Answer required for "Email Address"

Home phone

Number Required

Mobile Phone

Number Required

Ok to text?

Answer required for "Ok to text?"

Yes

Work Phone

Number Required

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Emergency Contact Information

List below names of three additional people who may be called in case of emergency or if child is sick in school.

Name*

Answer required for "Name"

Email Address*

Answer required for "Email Address"

Phone*

Number Required

Name*

Answer required for "Name"

Email Address*

Answer required for "Email Address"

Phone*

Number Required

Name*

Answer required for "Name"

Email addresss*

Answer required for "Email addresss"

Phone*

Number Required

No access: If there is a person who may NOT HAVE ACCESS to child please indicate:

Name

Answer required for "Name"

Order of Protection

Answer required for "Order of Protection"

Yes

Effective Date of Court Order

Answer required for "Effective Date of Court Order"

Health information

Name of Physician/Clinic

Answer required for "Name of Physician/Clinic"

Phone

Answer required for "Phone"

Answer Required

Allergist/immunologist

cardiologist

dermatologist

development/behavior specialist

neurologist

pulmonologist

Other:

Does child have any health condition that may affect participation in physical activities?

Answer required for "Does child have any health condition that may affect participation in physical activities?"

Yes

Other:

Known Diagnoses (check all that apply)

Answer required for "Known Diagnoses (check all that apply)"

Asthma

Seizures

Allergies/Anaphylaxis

Diabetes

None

Other:

Allergies

Answer required for "Allergies"

Milk

Eggs

Peanuts

Tree nuts

Fish

Shellfish

Soy

Wheat

Other:

My child has

Answer required for "My child has "

Private health insurance

Medicaid

No health insurance

It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail.
The recommendation of the parent as indicated above will be respected as far as possible.

Please list the names of any siblings and what schools they attend

Answer required for "Please list the names of any siblings and what schools they attend"

Signature of parent/guardian

Answer required for "Signature of parent/guardian"

By checking this box, I agree to be contacted by elected School, District, and/or City-wide parent leader volunteers regarding events, updates, and other matters connected to my school community

By checking this box, I agree that my contact information can be shared with elected School, District, and/or City-wide parent leader volunteers so I can be updated on events and other matters connected to my school community

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Emergency Contact Form (blue card)