Aquinas Academy

At St. Philomena Parish -- Livingston, NJ

Now accepting applications for the 2023-2024 school year!ADMISSIONS

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Extended Care Emergency Contact Form

- Parent Portal

The maximum number of form submissions has been reached. This form is currently not available.
- Student Information
  
  Student's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Current Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent Contact Information
  
  Mother's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Place of Business REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Work Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Place of Business REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Work Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Authorized to Pick-up
  
  Please provide all information requested for person(s) responsible for picking up your child. You must include your own name on this list.
  
  WE WILL NOT RELEASE YOUR CHILD TO ANYONE WHOSE NAME DOES NOT APPEAR ON THIS FORM.
- First Authorized Individual
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Student REQUIRED Please fill out this field. Please enter valid data.
  
  Daytime Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Second Authorized Individual
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Student REQUIRED Please fill out this field. Please enter valid data.
  
  Daytime Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Third Authorized Individual
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Student REQUIRED Please fill out this field. Please enter valid data.
  
  Daytime Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contacts
  
  If there is an emergency and we are unable to contact you, please list two (2) people that you would want us to contact (must be filled in).
- Emergency Contact #1
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Student REQUIRED Please fill out this field. Please enter valid data.
  
  Daytime Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact #2
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Student REQUIRED Please fill out this field. Please enter valid data.
  
  Daytime Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Medical Information
  
  Does your child have allergies? REQUIRED Please fill out this field.
  
  If yes, please list:
  
  Does your child have an Epi-pen? REQUIRED Please fill out this field.
  
  If yes, please give to the Main Office upon your arrival for Knight-for-a-Day.
- Thank you for submitting emergency information for extended care. If you have any questions or concerns, please contact our Eileen O'Neill at e[email protected],
  
  If you would like a summary of your submission, please enter your email address below.
- Email REQUIRED
  If you would like a summary of your submission, please provide your email address.
  Please fill out this field. Please enter an email address.
Submit

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