Prince George’s County Public Schools
H.S.A. AFTER-SCHOOL TUTORING EMERGENCY FORM

INSTRUCTION TO PARENTS: Complete all items on this form.  Sign and date where indicated.

When parents cannot be reached, list at least three people who may be contacted to pick up the child in an emergency:
1.  Name:  ______________________________Telephone:  _________________________
Address  __________________________________________________________________

2.  Name:  ______________________________Telephone:  _________________________
Address:  __________________________________________________________________

3.  Name:  ______________________________Telephone:  _________________________
Address:  __________________________________________________________________

Child’s Physician or Sources of Health Care_______________________________________
Address of Physician _________________________________________________________
Telephone ___________________________________

In an Emergency requiring medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM.
Your signature authorizes the responsible person at the facility to have your child transported to that hospital.

Signature of Parents/Guardian:____________________________Date:  ______________

Child’s Name:  __________________________Birth Date: _____________________
Child’s Home Address: _________________________________________________

Mother’s/Guardian’s Name:______________________________________________
Mother’s/Guardian’s Address (if different from above):  _____________________________________________________________________

Home #:_______________Work #:__________________ Cell Phone #:  ________________

Father’s/Guardian’s Name:  ____________________________________________________
Father’s/Guardian’s Address (if different from above): ____________________________________________________________

Home #:  _____________            Work #:  _____________Cell Phone #:   _____________________

If your child has a medical issue, which might require emergency medical care, please describe below:
____________________________________________________________________________________________

____________________________________________________________________________________________