Extended Care Contact & Release Form printable pdf download

St. Francis Central Catholic School

Extended Care Contact & Release Form

In the event that a parent / guardian will not be picking the student up

from the Keepers Program, or in the event of an emergency, we need

to know who your child may be released to. Additionally, the persons

listed may also be contacted in such events that parents cannot be reached.

Student Information

Child’s Name: ___________________________________________

Birthdate: __________________

Emergency Information

Physician’s Name: _______________________________________

Phone: _____________________

Please list any persons that we may contact in case of an emergency. My Child may be released to the

following persons for emergency and nonemergency situations unless otherwise noted.

*A Picture ID will be required if we cannot comfortably identify the person picking up your child.

Name: _______________________________________

Relationship: _______________________

Home Phone: ____________________ Cell: ____________________

Work: _____________________

Name: _______________________________________

Relationship: _______________________

Home Phone: ____________________ Cell: ____________________

Work: _____________________

Name: _______________________________________

Relationship: _______________________

Home Phone: ____________________ Cell: ____________________

Work: _____________________

Name: _______________________________________

Relationship: _______________________

Home Phone: ____________________ Cell: ____________________

Work: _____________________

Special Needs

____ No, my child has no special needs or allergies

____ Yes, My child has special needs or allergies

Please list any allergies, existing illness, previous serious illness/injuries, and/or any medications

prescribed for continuous, longterm use.

_________________________________________________________________________________________

In the event of an accidental ingestion of an allergen or problems relating to your child’s medical conditions,

please lost the proper procedures to be followed including any medications and proper doses.

_________________________________________________________________________________________

Parent / Guardian Signature: ___________________________________

Date: _______________

ECCRF rev. 072014

Extended Care Contact & Release Form