RMS EMERGENCY STUDENT DATA FORM

School No./Name

I.D. No.

Grade*

Section

Student's Last Name*

APP (I, II, III)

First Name*

Middle Name

Address*

street, city, state, zip code

Main contact phone number to be used for emergencies and automated messaging*

Registering Parent/Guardian's Name*

First and Last Name

Relation*

Place of Employment

Telephone*

Cellphone*

Email

example@example.com

Non-Registering Parent/Guardian's Name

Relation

Place of Employment

Telephone

Cellphone

Email

example@example.com

Is either parent in the Military?

YesNo

Branch

Kindergarten Only: Was the child in pre-school or child care?

YesNo

What type?

Was the full cost paid by you?

YesNo

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)*

First and Last Name

(Relation to Student)

(Relation to Student)(Address)

(Phone at Work)*

(Name)

First and Last Name

(Relation to Student)

(Relation to Student)(Address)

(Phone at Work)

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 notauthorized to take your child from school during the school day. Note that persons listed as emergency contacts are not authorizedto pick up your child, unless listed in this section.

Authorized Person # 1*

First and Last Name

Authorized Person # 2

First and Last Name

Authorized Person # 3

First and Last Name

Not Authorized Person # 1*

First and Last Name

Not Authorized Person # 2

First and Last Name

Not Authorized Person # 3

First and Last Name

IT IS THE PARENT'S RESPONSIBILITY 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*

Date

Printed Registering Parent/Guardian's Name*

First and Last Name

Registering Parent/Guardian's Signature*

Parents/guardians have the right to review the professional qualifications of their child's classroom teacher(s) including the licensing status, degree major, graduate degree(s) and the field of certification. This "right to know", available from your child's school, includes whether your child is receiving services provided by paraprofessionals and, if so, their qualifications.

Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his/her official duty shall be guilty of a misdemeanor of the second degree under Fla. Stat § 837.06, or whoever makes a false verified declaration is guilty of the crime of perjury, a felony of the third degree, under Fla. Stat. § 95.525, which are punishable as provided in Fla. Stat., §§ 775.082, 775.083 and 775.084.

The Emergency Student Data Form governs early release withdraw of the student. The registering parent/guardian must sign/verify this form and is responsible for providing truthful and accurate information. If the student's parents are divorced or separated, the enrolling parent is responsible for providing information that is consistent with the most recent court order governing such matters as divorce, separation or custody.

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