Emergency Student Data Form English

Emergency Student Data Form
School Name *
I.D. No. *
Grade *
Student's Last Name *
APP
Student's First Name *
Middle Name
Address *
Main contact phone number to be used for emergencies and automated messaging: *
Registering Parent/Guardian's Name *
Place of Employment
Relation *
Telephone
Cellphone *
Email
Non Registering Parent/Guardian's Name
Relation
Place of Employment
Telephone
Cell Phone
Email
example@example.com
Is either parent in the military? *

Yes No
If yes, what branch?
Emergency Contact Information

I authorize the school district to provide or secure any necessary emergency care for my child. It is the parent's legal responsibility to assume medical and transportation expenses for your child. In the event that parents of child cannot be reached, provide contact information below of two persons, by order of priority.
Name *
Relation to Student *
Address *
Phone *
Name
Relation to student
Address
Phone
Family Doctor
Phone
Preference of Hospital
Phone
Student health/allergy data which should be known in an emergency:
Authorization for release of students from school

Please provide the names of persons authorized or NOT authorized to take your child from school during the school day. Note that persons listed as emergency contacts are not authorized to pick up your child, unless listed in this section.
Authorized:
Authorized
Authorized
Authorized
Authorized
Authorized
Not authorized:
Not authorized
Not authorized
It is the parent's responsibilty

to inform the school in person of any changes in the information listed on this form. Under penalties of perjury, I declare that I have read the foregoing (document) and that the facts stated in it are true.
Date: *

Month Day Year
Date
Printed Registering Parent/Guardian's Name *
Registering Parent/Guardian's Signature *

Clear
Miami-Dade County Public School Media Release Parental Consent Form
School Name *
Date *

Month Day Year
Date
Dear Parent: Please be advised that during the year your child may be photographed, videotaped or interviewed at various school sponsored events. With your consent, the photograph, video or interview may be reproduced, and released for use in the media, i.e., newspapers, brochures, videos, television, the internet, and Miami-Dade County Public Schools websites and social media platforms such as Facebook, Twitter, etc.
Student's Name *
Student's ID *
Yes. *

Yes. My child's photograph/video/interview MAY be reproduced and released for use in the media. No. My child's photograph/video/interview MAY NOT be reproduced and released for use in the media.
Parent's Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Emergency Student Data Form

Emergency Contact Information

Authorization for release of students from school

It is the parent's responsibilty

Miami-Dade County Public School Media Release Parental Consent Form