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    Emergency Contact Form
    Posted on 08/22/2017

    Emergency Contact Form (pdf)

    SEATTLE PUBLIC SCHOOLS

    EMERGENCY INFORMATION AND STUDENT RELEASE FORM 2017-2018

    **** Please complete one form per child **** ID will be required to release students****

    SCHOOL: Hazel Wolf K-8

     

    Student’s Last Name_______________________________  First Name _________________________________

     

    Address_________________________________________  Phone ______________ Bus#________

     

    Grade/Teacher ­­­­­­­­­­­­­­­­­­­­­­­­___________________________________

     

    Full name of sibling(s) and grade(s)/teachers(s) enrolled at Hazel Wolf K-8:

     

     

     

    Parent/Guardian Name

     

     

    Home Phone

    Work Phone

    Cell Phone

    Parent/Guardian Name

     

     

    Home Phone

    Work Phone

    Cell Phone

     

    Emergency Contact Name

     

     

    Relationship

    Home Phone

    Work Phone

    Cell Phone

     

    GUARDIANS/NEIGHBORS TO WHOM STUDENT CAN BE RELEASED IN AN EMERGENCY(Please designate those authorized to pick up your child, keeping in mind the geographical location of the school your child attends. Feel free to list additional names on the back of this form)

     

    Name

     

     

    Relationship

    Home Phone

    Work Phone

    Cell Phone

    Name

     

     

    Relationship

    Home Phone

    Work Phone

    Cell Phone

    Name

     

     

    Relationship

    Home Phone

    Work Phone

    Cell Phone

     

    Please provide contact information for a friend or family member, who lives out of state, who can be contacted in the event local telephone service is Interrupted____________________________________________________

     

    MEDICATION OR CONDITIONS THAT REQUIRE ATTENTION IF A CHILD NEEDS OVERNIGHT CARE AT THE SCHOOL ARE AS FOLLOWS: __________________________________________________________________

     

    ___________________________________________________________________________________________


    (Provide nurse 72 hours of the essential medication and complete required “Medication Authorization” form.)

     

    EMERGENCY MEDICAL RELEASE:  In the event of a severe emergency or natural disaster such as an earthquake, it is recognized that I may not be able to be reached. Should such an incident occur, I authorize the Seattle School District to refer my child _______________________________as appropriate for any necessary medical treatment. It is my intent and understanding that this medical release be used only in a case of extreme emergency when attempts to reach me have failed.

     

    PARENT/GUARDIAN SIGNATURE____________________________________________    _________________