Request for Emergency
and Health Information
Date
NAME RELATIONSHIP TELEPHONE #
ADDRESS
CONFIDENTIAL INFORMATION BOX 1
Complete this box only if (1) it reflects
your child’s current living situation; OR (2)
it reflects your living situation if you are a
youth not living with a Parent or Guardian.
(Your answer will help school staff with
enrollment and may enable the student to
receive additional services.) Check one box:
in a car/park/other public place
doubled-up
in a hotel/motel
in a shelter
in transitional housing
School Note: If any box is checked,
see the CPS Policy 702.5.
CONFIDENTIAL INFORMATION BOX 2
Is there a current Order of Protection or No
Contact Order which concerns this student? YES NO
School Note: If “Yes,” follow CPS Policy 704.4 procedures. Enter information
in Legal Alert field and update contact information, as needed, in SIS.
Parent/Guardian and Emergency Contact Information: Add extra contacts on additional page, if needed.
PARENT/GUARDIAN CONTACT PARENT/GUARDIAN CONTACT
Contact Name
Relationship to Student
Check all that apply:
Lives With
Emergency
Gets Mailings
Permission to Pick up
Lives With
Emergency
Gets Mailings
Permission to Pick up
Home Address,
if different from student’s
(include unit number if applicable)
Cell Phone Number
Email Address
Name and Address of Employer
Work Phone Number
* Communication Language
* CPS communicates via phone calls. Select the language that should be used to communicate with you. Languages available for mass communication at this time are English and Spanish (note: other languages upon availability).
List the name of a relative or neighbor who can also be notied in an emergency and has permission to pick up the student:
NAME ADDRESS (include unit number if applicable) City State Zip
TELEPHONE #
Family Doctor’s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency.
STUDENT HEALTH INSURANCE: (select only one of the three)
Illinois Medical Card/All Kids: provide student’s medical ID # ___________________________________ (9-digit number located on back of card).
No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? YES NO
Private/Employer Health Insurance: no additional information needed.
CHILDREN OF MILITARY PERSONNEL (optional)
As the Parent or Guardian, are you a member of a
branch of the armed forces of the United States?
If yes, are you either deployed to active duty or expect
to be deployed to active duty during the school year?
YES NO
YES NO
PARENTS/GUARDIANS: The school must have on le emergency information that can be used to contact you. Please print clearly.
Whenever there is a change in this information, immediately notify the school in writing.
SCHOOL NAME STUDENT ID#
STUDENT LAST NAME FIRST NAME MIDDLE NAME
STUDENT HOME ADDRESS (include unit number if applicable) City State Zip
BIRTH DATE
(mm/dd/yyyy)
HOMEROOM # STUDENT HOME PHONE #
Parent/Guardian Signature
Must have an original signature; an electronic signature is not acceptable.
Von Steuben High School