Emergency Preparedness - Extended Care

Dear Parents,

The following information is needed for students enrolled in the Extended Care program. Space has been provided for you to list those people to whom the school may release your child in the event of an emergency situation. 

Student's name ________________________________ Age ____  Grade _____________

Student's name ________________________________ Age ____  Grade _____________

Student's name ________________________________ Age ____  Grade _____________

Home Address ___________________________________________________________

                        ___________________________________________________________

Home telephone (include area code) ___________________________________________

Business phone - Mother ___________________________________________________

                           Father  ___________________________________________________

Any additional (cell phone, pager, etc) _________________________________________

In case of an "Emergency" my child may be released to the following:

Father _______________________  Phone ____________________________________

Mother ______________________  Phone ____________________________________

Others:

Name: _______________________ Phone ____________________________________

Name: _______________________ Phone ____________________________________

Name: _______________________ Phone ____________________________________

Out of area contact:

Name: _______________________ Phone ____________________________________

Parent Signature : ________________________________________ Date ____________