Emergency Contact & Health Care Information

Please complete this form prior to the first class. Please log in to the website for pre-populated webform fields. An advantage of owning an Chesterbrook PTA Website Account/Profile is that webforms and Chipmunk Avenue orders are easier to complete because, assuming you are logged-in to the website, many of the form fields are pre-populated for you. If you are not logged-in and the funny looking stuff in some of the fields is disconcerting, just delete them.
Please enter the Order Number.
Have You Read The Chesterbrook PTA After-School Activity Policies? If not please click on the link and do so. It includes important information about pick-up and drop-off instructions.
LAST Name, FIRST Name
LAST Name, FIRST Name
Please provide the name(s) and description(s) of anyone who you do NOT want to pick-up your child(ren).
Please provide the name and telephone number of your health care provider.
Please provide the name and phone number of your health insurance company.
Authorization for the student to be transported to the emergency room and authorization fpr the hospital staff to provide treatment.
Please provide any additional information, e.g., SACC enrollment, allergies, physical limitations.

Our Chesterbrook PTA Sponsors and Chesterbrook ES Partners

The Chesterbrook PTA Executive Committee Thanks Our Generous School, Online Auction and PTA Sponsors!

Thanks, ATK . . . A Premier Aerospace Company! Corporate Visions, Inc., The Creative Ideas Company Thanks, Hier and Haines! Thank you, Chesterbrook Grandmother! Thanks, Wheat's Landscaping! Thanks, Decision Lens! Thanks, Jake Sullivan! Thanks, eSurance.com! Thank you, Khani Family! Thanks, Kristi Hedges Graninger! Thanks, Malasek Family! Thanks, D'Aquila Family! Thank you, Brandon Family! Thanks, Frank Langan!