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:
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