Elementary/Middle School Emergency Dismissal Form

EMERGENCY DISMISSAL FORM 2004-2005

Child's Name: ______________________________________________ Grade: ________________

Mother's Name: ______________________	Father's Name:______________________
Home Phone:_________________________	Home Phone:_______________________
Work Phone:________________________	Work Phone:_______________________
Home Address:_______________________	Home Address:_____________________

Doctor's Name: __________________________	Phone:____________________
Dentist's Name:______________________________	Phone:____________________

Please indicate any emergency/medical information we should know below:

_______________________________________________________________________________

In case either parent cannot be reached, please list the name(s) of the person(s) who you wish to be contacted, their relationship to you and telephone number

1st Name: _______________________________________________________________________

Relationship______________________________ Phone: ________________________________

2nd Name: _______________________________________________________________________

Relationship______________________________ Phone: ________________________________

If your child has your permission to go home with someone else because of an early dismissal, please fill in the information and sign below:

In case of an early dismissal, I give permission for _____________________________________

to go home with (in priority order):

1. _____________________________________________________________________________

2. _____________________________________________________________________________

Parent/Guardian Signature: _____________________________________ Date: ______________

Please fill out only one sheet if you have more than one child in school.