Emergency Contact/Authorized Pick-Up Persons

Emergency Contact/Authorized Pick-Up Person

Emergency Contact/Authorized Pick-Up Persons

Comments

This field is for validation purposes and should be left unchanged.

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The school has permission to contact the following adults for medical emergencies such as ER treatment, field trip permission or to pick up my child(ren) during or after school when I cannot be contacted.

Emergency Contact #1 – Full Name*

First Last

Emergency Contact #1 – Phone Number*

Emergency Contact #1 – Relationship*

Emergency Contact #2 – Full Name

First Last

Emergency Contact #2 – Phone Number

Emergency Contact #2 – Relationship

Emergency Contact #3 – Full Name

First Last

Emergency Contact #3 – Phone Number

Emergency Contact #3 – Relationship

Emergency Contact #4 – Full Name

First Last

Emergency Contact #4 – Phone Number

Emergency Contact #4 – Relationship

Emergency Contact #5 – Full Name

First Last

Emergency Contact #5 – Phone Number

Emergency Contact #5 – Relationship

Signature

NOTE: Students will not be allowed to leave with anyone not listed above. If for some reason you need someone other than those listed above to pick up your child you must notify the office ahead of time in writing or your child will not be allowed to leave with that person.

Signature of parent/guardian providing names of contact persons: *

First Last

Date*