Emergency/Early Release Information form

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    Printable Version of the Emergency/Early Release Information Form

    Student: ??????   School:??????   School Year:??????   

    Grade:??????   Teacher or Home Room:??????


    PLEASE COMPLETE ALL 4 SECTIONS OF THIS EMERGENCY FORM


    SECTION 1 EMERGENCY/EARLY RELEASE INFORMATION


    If my child must leave school prior to the end of the school day due to a medical appointment
    or other personal business matter, the following individuals are authorized to sign him/her out.
    Additionally, these individuals may be called if the school should need to contact someone
    during an emergency or in the event of an emergency dismissal prior to the end of the regularly
    scheduled school day.


    PLEASE LIST CONTACT PERSONS IN THE ORDER YOU WOULD LIKE THEM TO BE CALLED


    1. Name:??????   Home phone:??????

    Circle one:Parent/Guardian/Other   Work phone:??????   Cell phone:??????


    2.  Name:??????   Home phone:??????

    Circle one:Parent/Guardian/Other   Work phone:??????   Cell phone:??????


    3.  Name:??????   Home phone:??????

    Circle one:Parent/Guardian/Other   Work phone:??????   Cell phone:??????


    4.  Name:??????   Home phone:??????

    Circle one:Parent/Guardian/Other   Work phone:??????   Cell phone:??????



     SECTION 2 EARLY RELEASE PROCEDURES

    1. The parent, guardian or other contact person must report to the main office to sign out
      a student.
    2. The person signing out a student must provide a valid form of identification providing
      they are listed as a contact person.
    3. The person signing out a student must provide a signed excuse letter to the main office.
    4. The person signing out a student must fill in the appropriate blocks in the schools
      Student Sign Out Log.


    SECTION 3 EMERGENCY INSTRUCTIONS FROM PARENT 

    In the event of an emergency school or district wide dismissal, my child has been instructed to do the following: (Check One)

    GO HOME. My child can let himself/herself in the home or if my child arrives home and no one is there, my child should walk to the following address:

    • Resident’s Name/Relationship to Child:??????
    • Address:??????
    • Phone Number:??????

    DO NOT GO HOME. My child will go directly to the following address. (Within school attendance area):

    • Resident’s Name/Relationship to Child:??????
    • Address:??????
    • Phone Number:??????

    NOTE: Children at the elementary school level will not be released unless contact with a parent, guardian or emergency contact person has been made.



    SECTION 4 FAMILY CODE

    Parents or guardians may make a temporary change to the persons listed in BLOCK 1 of this form by contacting the schools main office. You must provide us, on the line below, with your own identification number or code name in order to make these changes. Any long term or permanent changes must be done in writing and should also reference this code. This code should be safeguarded to avoid unauthorized changes to this form. YOU WILL RECEIVE ONE OF THESE FORMS FROM EACH SCHOOL THAT YOUR CHILDREN ATTEND. PLEASE COMPLETE AND RETURN THE FORMS TO EACH SCHOOL. USE THE SAME CODE FOR ALL OF YOUR CHILDREN ATTENDING SCHOOL IN THE DISTRICT.

    I have selected the following identification number or code name: ??????

    Parent or Guardian Signature: ??????   Date:??????



    SCHOOL USE ONLY: COPY DISTRIBUTION (check all that apply)

    • MAIN OFFICE????
    • MEDICAL OFFICE????
    • EMERGENCY FILE????