Parent/Student Emergency Contact Information

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Please complete this survey to update your child's emergency contact information for the 2020-2021 school year. Is is very important to contact Ms. Gary to update any of this information if it changes. This is the only method of communication we have to update you with the most recent information.

STUDENT INFORMATION

Student Last Name *

Student First Name *

Student Middle Name *

(Type N/A if they don't have one)

Student Grade *

00-Pre-K

0-Kindergarten

Student ID Number *

Homeroom Teacher *

James

Johnson

Font

Perez

Henry

Berman

Srebnick

Luxenburg

Reid

Sawyer-Hill

Abdella

Ferguson

Allen-Williams

Jefferson

Bush

Caddle

Orr

Parker

Talbert

Wasserman

Carpenter

Home Address *

(Street, City, State, Zip code)

PARENT INFORMATION

Registering Parent Name *

Registering Parent Relation *

Mother

Father

Grandparent

Foster Parent

Aunt/Uncle

Other

Registering Parent Place of Employment *

Registering Parent Cell Phone Number *

Registering Parent Work Number *

(Type N/A if non applicable)

Registering Parent Email Address *

Non-Registering Parent Name *

Non-Registering Parent Relation *

Mother

Father

Grandparent

Foster Parent

Aunt/Uncle

Other

Non-Registering Parent Place of Employment *

Non-Registering Parent Cell Phone Number *

Non-Registering Parent Work Number *

(Type N/A if non applicable)

Non-Registering Parent Email Address *

EMERGENCY CONTACT INFORMATION

Full Name (Contact #1) *

Relation to Student (Contact #1)

Full Address (Contact #1) *

Phone Number (Contact #1) *

Full Name (Contact #2) *

Relation to Student (Contact #2) *

Full Address (Contact #2) *

Phone Number (Contact #2) *

AUTHORIZATION FOR RELEASE OF STUDENT FROM SCHOOL

Please provide the names of persons authorized or Not authorized to take your child from school during the school day. NOTE: persons listed as emergency contacts are not authorized to pick up your child, unless listed in this section. This information will be used once we moved into Phase II and Phase III.

I authorize the following people to pick my child up from school. *

Include first and last names

I DO NOT authorize the following people to pick my child up from school. *

Include first and last names

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