Please complete and sign the form below.

FAMILY INFORMATION

GUARDIAN (1)

GUARDIAN (2)

STUDENT INFO (1)

STUDENT INFO (2)

STUDENT INFO (3)

STUDENT INFO (4)

PERSONS (OTHER THAN GUARDIANS) AUTHORIZED TO PICK UP MY CHILD(REN):

EMERGENCY CARE INFORMATION:  List TWO relatives, friends, neighbors or friends to whom you delegate full authority and temporary care of your child if IF YOU CANNOT BE REACHED IMMEDIATELY.

PERSON 1

PERSON 2

PHYSICIAN INFORMATION 

In case of an emergency, I AUTHORIZE THE SCHOOL TO CALL THE PHYSICIAN LISTED OR ANOTHER IF HE/SHE CANNOT BE REACHED AND FOLLOW THEIR INSTRUCTIONS:

CHOICE OF HOSPITAL

I AUTHORIZE THE SCHOOL TO CALL AN AMBULANCE OR PARAMEDICS OR FIRE DEPARTMENT AND TO FOLLOW THEIR INSTRUCTIONS.  THE SCHOOL DOES NOT ASSUME RESPONSIBILITY IN THE ABOVE EMERGENCY PROCEDURES USED AND DOES NOT ASSUME PAYMENT FOR MEASURES TAKEN.

GUARDIAN SIGNATURE

If your prefer to fill out a paper emergency form, download this form and return a signed copy to the office.