WALLKILL VALLEY REGIONAL HIGH SCHOOL

                                                   EMERGENCY CONTACT INFORMATION

Last Name________________________ First_____________________ Date of Birth______________

Address___________________________________________________ School___________________

City______________________________________ Zip______________Grade___________________

Home Telephone (       )______________________ Cell Telephone_____________________________

TO PARENT OR GUARDIAN:   To serve your child in case of accident or sudden illness, it is necessary  that

You give the following information for emergency calls:

                               Name                                    Address                              Telephone

Mother/__________________ Home_____________________      _____________ Work____________

Father/___________________ Home______________________     _____________Work____________

Or Guardian______________ _Home_______________________    _____________Work___________

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

Name____________________________________ Name______________________________________

Home/Address____________________________   Home______________________________________

Work___________________________________     Work______________________________________