NYCDOE 2025-26 Emergency Contact Form

Student Information

Email *

Student Last Name *

Student First Name *

Date of Birth

Gender (optional)

Student ID (if known)

2025-26 Teacher/Class

Primary Parent/Guardian

Name of Parent/Guardian (primary) *

Relationship to Student

Preferred Language (written)

Preferred Language (spoken)

Home Phone

Work Phone

Mobile Phone *

Parent/Guardian Email *

Borough

Other Parent/Guardian

Name of Other Parent/Guardian

Relationship to Student

Mobile Phone

Other Parent Email

Emergency Contacts

Emergency Contact #1 Name *

Emergency Contact #1 Phone *

Emergency Contact #1 Relationship

Emergency Contact #2 Name

Emergency Contact #2 Phone

Emergency Contact #2 Relationship

Emergency Contact #3 Name

Emergency Contact #3 Phone

Emergency Contact #3 Relationship

Health Information

Name of Physician/Clinic

Physician Phone

Health conditions affecting participation (e.g. gym, stairs)

Allergies (list)

Health Insurance: Does student have coverage?

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