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BLUE CARD
INFORMATION COLLECTED FOR THE DOE EMERGENCY CONTACT CARD
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* Indicates required question
Email
*
Your email
Student LAST name
*
Your answer
Student FIRST name
*
Your answer
STUDENT DATE OF BIRTH
*
MM
/
DD
/
YYYY
STUDENT CELL PHONE NUMBER
*
Your answer
PARENT/GUARDIAN NAME (Primary/students lives with)
*
Your answer
Relationship
*
Your answer
PARENT/GUARDIAN Preferred language of Communication
*
English
Spanish
Arabic
Haitian Creole
Other:
Required
Parent/Guardian CELL PHONE#
*
Your answer
Parent/Guardian EMAIL address
*
Your answer
Primary Guardian Home address (with apt#)
*
Your answer
Borough
*
Brooklyn
Queens
Bronx
Staten Island
Manhattan
Other:
Required
Parent/Guardian CELL PHONE#
*
Your answer
zipcode
*
Your answer
HEALTH ALERT & LIMITATIONS Please describe any health condition that we need to be aware of including any that may affect participation in physical activities or limit mobility.
*
Your answer
ALLERGIES
Your answer
Name & Contact # of Physician
*
Your answer
Other Guardian
Your answer
Relationship
Your answer
Parent/Guardian EMAIL address
Your answer
Is there anyone who may NOT HAVE ACCESS to student?
Your answer
Please list 3 persons (names & numbers) we may try to contact if we can not reach you.
*
Your answer
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