42 Maynard Road, Old Saybrook, CT
Phone: (860) 388-0849 | Fax: (860) 388-6265

Educating the Whole Child from Pre-K3 to Grade 8

St. John School Student Emergency Contact Information

Family Last Name

Your Email

Street

City

State

Zip

Student #1 Name

Please list all students in family at SJS

Student Date of Birth

Grade

Allergies (Yes/No)

If YES to ALLERGIES, please list

Student #2 Name

Student Date of Birth

Grade

Allergies (Yes/No)

If YES to ALLERGIES, please list

Student #3 Name

Student Date of Birth

Grade

Allergies (Yes/No)

If YES to ALLERGIES, please list

Student #4 Name

Student Date of Birth

Grade

Allergies (Yes/No)

If YES to ALLERGIES, please list

Parent/Guardian #1 Name

First & Last Name

Relationship

Lives with Child (Yes/No)

Home Phone

Cell Phone

Employer

Email

Parent/Guardian #2 Name

Relationship

Lives with Child (Yes/No)

Home Phone

Cell Phone

Employer

Email

Student's Physician

Physician's Phone

Student's Dentist

Dentist's Phone

In the event of a serious medical emergency or accident, and I cannot be reached, I authorize the school personnel to have my child treated by a readily available physician, hospital or emergency facility.

Yes No

Parent/ Guardian Name

Date

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Accredited Member - New England Association of Schools & Colleges

A teaching apostolate of the Sisters of Charity of Our Lady Mother of the Church (SCMC)

Saint John School
42 Maynard Road Old Saybrook, CT 06475
(860) 388-0849 |

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Educating the Whole Child from Pre-K3 to Grade 8

St. John School Student Emergency Contact Information

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