Emergency Contact Form

EMERGENCY CONTACT AND MEDICAL INFORMATION
We want our students to have a happy and enriching experience at the LASC. Please provide us with any information that could assist in attaining this goal. This information is confidential and will only be shared with staff members involved directly with the student. Please submit this form prior to the first day of class. Emergency contact forms are good for one year starting at the beginning of each summer. If you have already submitted a form, and there are no changes, there is no need to submit a new on.
Please fill out the form below and click submit. If you would prefer, you can click the images at the bottom of the page to open (or download) the PDF version of the Emergency Contact Form. You can then print the form, fill it out, and return to the Living Arts & Science Center.

Emergency Contact - Medical Information - Photo Release

Student's name:
Date of Birth: (mm/dd/yyyy)
Last Grade Completed:

Parents/Guardians (if student is under 18)
Name: Relationship
Name: Relationship

Please provide us with your current phone number(s) and indicate the owner of each number:
Home Phone: Whose phone is this?
Work Phone: Whose phone is this?
Cell Phone: Whose phone is this?

Place(s) of Employment:
E-Mail(s):

Who will normally provide transportation?
(Include first and last names of all transportation, including parents/guardians listed above. We require a
signed note for anyone else to pick up a student under 18.)

Emergency Contact Name(someone NOT listed above):
Phone #:
Relationship to student:

1. What are your expectations for you or your child’s class experiences at the LASC?

2. Please list student allergies as well as all medical, physical, emotional and social concerns.

3. Do you have any other concerns or suggestions for those working with you or your child?

I have read, understand, and agree to adhere to LASC guidelines and policies found here.
 Yes

I give permission for the Living Arts & Science Center or those designated by the LASC to collect and use the likeness, photograph, voice, written word, artwork or direct quotes of the above named student. Such documentation may be used on the LASC website, in promotional materials, the newspaper, or other such materials. I release the Living Arts & Science Center from any liability or responsibility for this use.

By entering your name below you are acknowledging that the information entered herein is accurate.
Name: Date: (mm/dd/yyyy)

captcha
Please enter the text/numbers exactly as they appear


You must have Adobe Acrobat Reader on your computer to open the forms.

www.iiethai.org/web/profile_del.php