Austin Japanese School
Student Emergency Card
子 怪我や急病 保護者 連絡 い場合 治療 受け 際 記 情報 病院へ提出す 必要
あ ます 英語 記入く い ＿＿＿＿＿学年
Student’s Name
(last name) (First name) (Middle name)
Sex: F / M
Birth Date (Month/Date/Year) Home phone No.
Address (Street) (City) (State) (Zip)
TO PARENT OR GUARDIAN: To serve our child in case of ACCIDENT OR SUDDEN ILLNESS. It is necessary that you furnish the following information for emergency calls: 記以外 緊急連絡先
Father’s Name Phone No.
Mother’s Name Phone No.
NAME OF AUTHORIZED PERSON (RELATIVE, NEIGHBOR OR FRINED) TO CALL IF PARENT(S) CAN NOT BE REACHED. (両親以外 緊急連絡者)
Name Phone No.
Name Phone No.
HEALTH INFORMATION: Briefly list any factor or medical conditions/ allergies of which school officials
should be aware: (ア ーや疾患 学校 知 い 方 よい 思わ 記 記入し く
い )
Local doctor Phone No.
Insurance Co. Name Policy No.
In the event my child becomes ill or injured at school and I cannot be reached, Austin Japanese School is authorized to contact any of the people listed above, or take my child to the physician indicated or to a hospital, or to call 911 for emergency care depending on the severity of the illness or injury. 私 子供 緊急時 連絡
い場合 ースチン日本語補習授業校 記 緊急連絡者 連絡す ホームド ターや病院 連 行
く 病気や怪我 重傷 あ 救急車 呼ぶ 認めます
__________________________________ ____________________________________ _______________ Printed Name of Parents/Guardian Signature of Parent or Legal Guardian Date
* フ ーム 毎年4月 更新す 必要 あ ます
日本語 姓：
