ALTERNATE EMERGENCY CONTACT & PICK-UP AUTHORIZATION

December 17, 2008

The information in this form is to be given to the classroom teacher. If a student has a Chronic Illness, please complete the Chronic Illnes Form to be filed with this form.

Student’s Full Name:

Physician’s Name:

Phone:

If student’s parents/guardians are not available for an emergency, please contact the following:

(ISL WILL NOT RELEASE YOUR CHILD TO ANYONE AGED 16 OR UNDER)

1. Name:
Relation to student:

Home Number:
Work Number:

Cell 1 Number:
Cell 2 Number:

2. Name:
Relation to student:

Home Number:
Work Number:

Cell 1 Number:
Cell 2 Number:

3. Name:
Relation to student:

Home Number:
Work Number:

Cell 1 Number:
Cell 2 Number:

4. Name:
Relation to student:

Home Number:
Work Number:

Cell 1 Number:
Cell 2 Number:

Individuals authorized to pick-up my child from school (different from above):

1. Name:
Phone Number:

2. Name:
Phone Number:

3. Name:
Phone Number:

4. Name:
Phone Number:

Parent Signature:
Date:

www.isl-edu.org