Eaton RESA Career Preparation Center Emergency Information
Student's Name *
Your answer
Program: *
Grade: *
Address: *
Your answer
Home Phone #: *
Your answer
Student - Cell Phone #: *
Your answer
Birthdate: *
MM
/
DD
/
YYYY
Student home e-mail address (NOT SCHOOL): *
Your answer
Student Resides With: *
Your answer
Where parent/guardian can be reached if not at home:
Mother's Name: *
Your answer
Mom - Home Phone #: *
Your answer
Mom - Cell Phone #: *
Your answer
Mom - Work Phone #: *
Your answer
Mom - Address: *
Your answer
email address most used by Mom: *
Your answer
Send reports to this mailing address? *
Father's Name: *
Your answer
Dad - Home Phone #: *
Your answer
Dad - Cell Phone #: *
Your answer
Dad - Work Phone #: *
Your answer
Dad - Address: *
Your answer
email address most used by Dad: *
Your answer
Send reports to this address? *
Please choose one: *
I hereby grant permission for the above student to participate in district approved, class related field trips supervised by the instructor. *
I hereby grant Eaton RESA Career Preparation Center, Lansing Community College, Davenport University, AIS Construction, Olivet College, Potter Park Zoo or Farm Bureau permission to photograph/videotape my child as they deem necessary for school use and/or media release. *
I hereby grant permission for my student to be transported by an Eaton RESA staff member, when necessary. *
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