Emergency | Vine Academy

Vine Academy

Student Emergency Form

Year 2026 to 2027

Student First Name

Student Last Name

Student Date of Birth

Month

Day

Year

Student Cell Phone (if any)

Mother's Name

Mother Cell #

Mother Employer

Mother Work #

Father's Name

Father Cell #

Father Employer

Father Work #

Home Address

Home Phone

Parent Email (most used)

Student Physician

Physician Phone #

Health Insurance Company

Health Insurance Policy #

Group #

Is the student currently taking any medication?

If yes, name of medication

Allergies (food & medication)

Other Medical Conditions

Last Tetanus Vaccination

Month

Day

Year

Emergency Contact (other than parent)

Phone

Relationship to Student

Emergency Contact (other than parent)

Phone #

Relationship to Student

In Case of Area Disaster - Contact living outside the Bay Area Name

Phone #

PARENT WAIVER for emergency medical treatment: If my child needs medical treatment either on campus or off campus during school hours, I understand that all efforts will be made to contact me before my child received treatment. However, I give my consent for any emergency medical treatment needed and I understand that I am responsible for all costs incurred.

Father's Signature

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Mother's Signature

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Class Schedule

Calendar

Vine Academy

Student Emergency Form