Emergency Contact And Release From School Information

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Emergency Contact and Release from School Information
Rev. 12/2015
It is your responsibility to ask for another copy of this form and deliver it to the School Office whenever you wish to update this information.
The Emergency Form is our direct line of communication to you when you are needed in an emergency. We thank you for remembering this and
appreciate your help as we endeavor to serve you.
Emergency Contact Information:
An accident or extreme illness of a student makes it necessary for school personnel to contact the parent to
get permission for emergency referral. The legal responsibility for medical and transportation expense incurred on behalf of your child is a parental
one. By signing this form, you authorize first aid treatment using basic first aid supplies to be provided to your child as needed. In the event that a
parent or Emergency Contact cannot be reached, you give permission for the School to arrange for necessary medical care. You understand and
agree that you will be financially responsible for all aspects of such emergency medical care and you indemnify and hold the School harmless for all
damages, claims, and amounts paid or due in connection with such emergency medical care.
STUDENT INFORMATION
Last Name: __________________________________________________
First Name: ___________________________________________________
Home Address: ______________________________________________
City/State/Zip: _________________________________________________
Home Phone: _________________________________
Doctor: _________________________
Phone: ___________________________________
Hospital: ________________________________________________________________________
Phone: ___________________________________
Student health data which should be known in an emergency: _______________________________________________________________________
PARENT 1 INFORMATION
Last Name: __________________________________________________
First Name: ___________________________________________________
Home Address: ______________________________________________
City/State/Zip: _________________________________________________
Place of Employment: __________________________
Position: __________________________ Work Phone: ______________________________
Home Phone: _________________________________
Cell Phone: ________________________ Fax: _____________________________________
E-mail: _______________________________________________________________________________________________________________________
PARENT 2 INFORMATION
Last Name: __________________________________________________
First Name: ___________________________________________________
Home Address: ______________________________________________
City/State/Zip: _________________________________________________
Place of Employment: __________________________
Position: __________________________ Work Phone: ______________________________
Home Phone: _________________________________
Cell Phone: ________________________ Fax: _____________________________________
E-mail: _______________________________________________________________________________________________________________________
ALTERNATIVE CONTACT #1
Name: ______________________________________________________
Relation: ____________________ Phone: _________________________
Cell Phone: __________________________________________________
Address: ______________________________________________________
ALTERNATIVE CONTACT #2
Name: ______________________________________________________
Relation: ____________________ Phone: _________________________
Cell Phone: __________________________________________________
Address: ______________________________________________________
Release of Student Information:
List below those persons authorized to take your child from School during the school day. If any person
previously listed on this form is NO LONGER AUTHORIZED to take the student, please call the Campus Secretary where your child is enrolled.
PERSONS AUTHORIZED TO PICK UP STUDENT
_______________________________________________________________
____________________________________________________________
_______________________________________________________________
____________________________________________________________
 Your child will not be released to any person not listed above.
A Driver’s License must be presented for authorization.
It is the responsibility of the parent to inform the School of any changes in the information listed on this form.
Any additional information or comments: __________________________________________________________________________________________
Parent Signature: ___________________________________________________________________ Date: _____________________________________
For more information visit
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