NJ Family Care Emergency Medical Form - New Jersey

Guardian

Address Address

NAME OF SCHOOL DISTRICT

____________________________________________________________________

ID#__________________________________

Last Name____________________________ First____________________Initial_____ Date of Birth (Mo/Day/Year)___________________

Address________________________________________________________________ School_____________________________________

City____________________________________________Zip_____________________ Grade______________________________________

Work ____________________________________ ________________________________

List two neighbors or nearby relatives who will assume temporary care of your child if you cannot be reached:

Name_____________________________________________________ Name_____________________________________________________

Home/____________________________________________________ Home/____________________________________________________

Work/_____________________________________________________ Work/_____________________________________________________

Telephone: Home___________________ Work___________________ Telephone: Home___________________ Work___________________

Please list other children attending New Jersey Public Schools (Name, School)