Emergency Info And Student Release Form printable pdf download

SEATTLE PUBLIC SCHOOLS

EMERGENCY INFORMATION AND STUDENT RELEASE FORM

SCHOOL_

Student’s Last Name

First Name

Address

Phone

Bus#

Grade

Name of sibling(s) enrolled at same school

Parent/Guardian Name_________________________________________________________________________

Home Phone_____________________ Work Phone_________________ Cell Phone_______________________

Parent/Guardian Name_________________________________________________________________________

Home Phone_____________________ Work Phone_________________ Cell Phone_______________________

Emergency Contact Name_____________________________ Relationship_______________________________

Home Phone_____________________ Work Phone _________________ Cell Phone _______________________

GUARDIANS/NEIGHBORS TO WHOM STUDENT CAN BE RELEASED IN AN EMERGENCY: (Please designate

those authorized to pick up your child, keeping in mind the geographical location of the school your child attends.)

Name _____________________________________________ Relationship ______________________________

Home Phone_____________________ Work Phone_________________ Cell Phone_______________________

Name _____________________________________________ Relationship ______________________________

Home Phone_____________________ Work Phone_________________ Cell Phone_______________________

Please provide contact information for a friend or family member, who lives out of state, who can be contacted in

the event local telephone service is Interrupted

MEDICATION OR CONDITIONS THAT REQUIRE ATTENTION IF A CHILD NEEDS OVERNIGHT CARE AT THE

SCHOOL ARE AS FOLLOWS:

(Provide 72 hours of the essential medication and complete required “Medication Authorization” form.)

EMERGENCY MEDICAL RELEASE: In the event of a severe emergency or natural disaster such as an

earthquake, it is recognized that I may not be able to be reached. Should such an incident occur, I authorize the

Seattle School District to refer my child

_as appropriate for any necessary

medical treatment. It is my intent and understanding that this medical release be used only in a case of extreme

emergency when attempts to reach me have failed.

PARENT/GUARDIAN SIGNATURE

Date Signed

Revised 8/8/2016

Emergency Info And Student Release Form