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2026 SUZUME NO GAKKO EMERGENCY/DISASTER RELEASE FORM 
You must complete a separate form for each child. A copy of this form will be emailed to parent/guardian emails included in the form. Print 1 copy to place in the Emergency Food Bag, due 1st day of session. 

SUGGESTED FOOD & SUPPLIES (everything must fit into ONE GALLON SIZED BAG and you must be able to close it. Please label the bag clearly with your child's name)
  • Cracker packs
  • Beef Jerky
  • Granola bars
  • Dried fruits
  • Fruit Snacks
  • 2 16oz bottles of water
  • Family Picture
Email *
Student Last Name *
Student First English Name *
Student Japanese Name *
Grade - Teacher (Please select grade they will be entering in the FALL) *
Gender *
Student Lives With (choose all that apply) *
Required
Parent/Guardian 1 First Name *
Parent/Guardian 1 Last Name *
Parent/Guardian 1 Email *
Parent/Guardian 1 Cell Phone # *
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Email
Parent/Guardian 2 Cell Phone Number
Student Home Address (Street Address, City, State, Zip) *
Student's Birthdate *
MM
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Emergency Contacts
In case of my child's illness or injury and the school is unable to reach me, I give my consent to call or release my child to any of the following persons. I also authorize the named persons to pick up my child from school in the event of a major disaster (e.g. earthquake, flood)
Emergency Contact 1 Name *
Emergency Contact 1 Phone # *
Emergency Contact 1 Relationship to Child *
Emergency Contact 2 Name *
Emergency Contact 2 Phone # *
Emergency Contact 2 Relationship to Child *
Emergency Contact 3 Name
Emergency Contact 3 Phone #
Emergency Contact 3 Relationship to Child
HEALTH INFORMATION
Health conditions (select all that apply)
Additional comments on food allergies or other health conditions
Is your child restricted from physical activity at all? (if you select Yes please add comments below) *
Additional comments on restrictions from physical activity
List any needed medications
Doctor's Name and Phone # *
Health Insurance Carrier *
Health Insurance Policy # *
Dentist's Name & Phone Number *
Dental Insurance Carrier *
Dental Insurance Policy # *
If you have other children attending Suzume no Gakko please list their name and grades below *
BY ENTERING YOUR NAME BELOW SUBMITTING THIS FORM you hereby agree and certify that you are the person listed below, that you are a parent or legal guardian to the student in this form, and that in an EMERGENCY, if you cannot be reached, you hereby give permission to the school to call 911 and/or take your child to an emergency hospital by ambulance. You are additionally verifying that the information on this form is correct and understand that it is my responsibility to keep this form current and up-to-date.Untitled Title
Full Name *
Relationship to Student *
Date *
MM
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DD
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YYYY
A copy of your responses will be emailed to .
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