Community Christian Academy
Summer Fun 2008 

Student Emergency Information

Date   Grade   Student's Date of Birth

Student            
             First                            M.I.              Last

Home Phone

Address
                  Street                                                   City                      State      Zip

Father's Name    

Father's Employer

Mother's Name

Mother's Employer

Responsible adult to contact if parents cannot be reached:

Name    Telephone

Name    Telephone

Allergies

Preferred Physician

I do   /   do not    authorize Community Christian Academy to administer
first aid, or take my child to a doctor/hospital for treatment if none of these
above can be reached.

School Pick-Up Authorization

The following people are authorized to pick my child up from school  


Parent Name