2023-2024 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

Middle Name

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

OSIS Number*

Answer Required

Primary Guardian Information

This Guardian Can:*

Answer Required

Be contacted in emergencies

Pick up student

Receive School mailings

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

Answer Required

Relationship to Student*

Answer Required

Preferred Language of Communication*

Answer Required

Home Phone*

Answer Required

Mobile Phone*

Answer Required

Ok to text*

Answer Required

Yes

Work Phone

Answer Required

Email Address*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Question

Number Required

Zip Code / Postal Code*

Answer Required

Additional Guardian Information

This guardian can*

Answer Required

Be contacted in emergencies

Pick up student

Receive School Mailings

First Name*

Answer Required

Last Name*

Answer Required

Relationship to student*

Answer Required

Email Address*

Answer Required

Home phone*

Number Required

Mobile Phone*

Number Required

Ok to text?*

Answer Required

Yes

Work Phone

Number Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

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

Email Address*

Answer Required

Phone*

Number Required

Name*

Answer Required

Email Address*

Answer Required

Phone*

Number Required

Name*

Answer Required

Email addresss*

Answer Required

Phone*

Number Required

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

Name

Answer Required

Order of Protection

Answer Required

Yes

Effective Date of Court Order

Answer Required

Health information

Name of Physician/Clinic

Answer Required

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

Yes

Other:

Known Diagnoses (check all that apply)

Answer Required

Asthma

Seizures

Allergies/Anaphylaxis

Diabetes

None

Other:

Allergies

Answer Required

Milk

Eggs

Peanuts

Tree nuts

Fish

Shellfish

Soy

Wheat

Other:

My child has

Answer Required

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

Signature of parent/guardian

Answer Required

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.

2023-2024 Emergency Contact Form (blue card)