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Blue Card

Student Last Name*

Answer Required

Student First Name*

Answer Required

Student Middle Initial

Answer Required

Student Date of Birth*

Answer Required

Student Sex*

Answer Required

Student ID#

Answer Required

Parent/ Guardian (Student resides with)*

Answer Required

Relationship*

Answer Required

Parent's Preferred Language of Communication Written*

Answer Required

Parent's Preferred Language of Communication Oral*

Answer Required

Home Phone*

Number Required

Work Phone

Number Required

Mobile Phone*

Number Required

E-mail

Answer Required

Address*

Answer Required

Apt. *

Answer Required

Borough*

Answer Required

Zip*

Answer Required

Other Parent/ Guardian

Answer Required

Parent's Preferred Language of Communication Written

Answer Required

Parent's Preferred Language of Communication Oral

Answer Required

Home Telephone

Answer Required

Work Telephone

Answer Required

Mobile Phone

Answer Required

E-mail

Answer Required

Address

Answer Required

Apt.

Answer Required

Borough

Answer Required

Zip

Answer Required

List below names of three (3) persons who may be called in case of emergency or if child is sick in school.

CHILD WILL BE RELEASED ONLY TO PERSONS NAMES ON THIS CARD.

Name*

Answer Required

Telephone *

Answer Required

Relationship*

Answer Required

Name

Answer Required

Telephone

Answer Required

Relationship

Answer Required

Name

Answer Required

Telephone

Answer Required

Relationship

Answer Required

If there is a person who many NOT HAVE ACCESS to child, please indicate:

Name

Answer Required

Relationship

Answer Required

Order of Protection Exists? Yes or No

Answer Required

Principal will be notified in writing of any changes to information on this card.

Signature*

Signature Required

Grade

Answer Required

Class

Answer Required

Room Number

Answer Required

Teacher

Answer Required

HEALTH INFORMATION

Name of Physician/Clinic *

Answer Required

Physician/ Clinic Telephone*

Answer Required

Health Alert

Does child have any health condition that may affect participation in physical activities? Yes or No*

Answer Required

Limitations (i.e., stair climbing, participation in gym)*

Please write N/A if none

Answer Required

Allergies*

Please write N/A if none

Answer Required

504 services for the current year? Yes or No

Answer Required

Previous Year? Yes or No

Answer Required

If "No Health Insurance," are you willing to share contact information from this card to learn about insurance options?

Please indicate Yes or No

Answer Required

If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?

Answer Required

It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail.

The parent's recommendation, as indicated above, will be respected as far as possible.

Siblings Last Name, First Name, School of Attendance

Answer Required

Siblings Last Name, First Name, School of Attendance

Answer Required

Siblings Last Name, First Name, School of Attendance

Answer Required

Confirmation Email

Confirmation Email *

Email Required