Emergency Contact Update Form

Dear Parent/Guardian,

Please help us ensure that we have the correct Emergency Contact and Pick Up information for your child. For each individual, please provide a full name, relationship to student, phone number and check the box under each role or permission that applies (i.e. authorized to pick up, emergency contact, NOT permitted to pick up your child).

Thank You,
Main Office
Student 1 Name*
Student 1 Grade*
Student 2 Name
Student 2 Grade
Student 3 Name
Student 3 Grade
Emergency Contact and Pick-Up Information
1) Name of Individual [1]

First NameLast Name
Relationship to Student [1]
Phone Number [1]
Please enter a valid phone number.
Is this person authorized to Pick Up your student? [1]

Yes, this person is authorized to Pick Up my student
Is this person an Emergency Contact for your student? [1]

Yes, this person may be contacted in an emergency in case I am unable to be reached
Is this person NOT permitted to Pick Up your student? [1]

Yes, this person is NOT permitted to Pick Up my student

Click to add another individual [2]
2) Name of Individual [2]

First NameLast Name
Relationship to Student [2]
Phone Number [2]
Please enter a valid phone number.
Is this person authorized to Pick Up your student? [2]

Yes, this person is authorized to Pick Up my student
Is this person an Emergency Contact for your student? [2]

Yes, this person may be contacted in an emergency in case I am unable to be reached
Is this person NOT permitted to Pick Up your student? [2]

Yes, this person is NOT permitted to Pick Up my student

Click to add another individual [3]
3) Name of Individual [3]

First NameLast Name
Relationship to Student [3]
Phone Number [3]
Please enter a valid phone number.
Is this person authorized to Pick Up your student? [3]

Yes, this person is authorized to Pick Up my student
Is this person an Emergency Contact for your student? [3]

Yes, this person may be contacted in an emergency in case I am unable to be reached
Is this person NOT permitted to Pick Up your student? [3]

Yes, this person is NOT permitted to Pick Up my student

Click to add another individual [4]
4) Name of Individual [4]

First NameLast Name
Relationship to Student [4]
Phone Number [4]
Please enter a valid phone number.
Is this person authorized to Pick Up your student? [4]

Yes, this person is authorized to Pick Up my student
Is this person an Emergency Contact for your student? [4]

Yes, this person may be contacted in an emergency in case I am unable to be reached
Is this person NOT permitted to Pick Up your student? [4]

Yes, this person is NOT permitted to Pick Up my student

Click to add another individual [5]
5) Name of Individual [5]

First NameLast Name
Relationship to Student [5]
Phone Number [5]
Please enter a valid phone number.
Is this person authorized to Pick Up your student? [5]

Yes, this person is authorized to Pick Up my student
Is this person an Emergency Contact for your student? [5]

Yes, this person may be contacted in an emergency in case I am unable to be reached
Is this person NOT permitted to Pick Up your student? [5]

Yes, this person is NOT permitted to Pick Up my student

Click to add another individual [6]
6) Name of Individual [6]

First NameLast Name
Relationship to Student [6]
Phone Number [6]
Please enter a valid phone number.
Is this person authorized to Pick Up your student? [6]

Yes, this person is authorized to Pick Up my student
Is this person an Emergency Contact for your student? [6]

Yes, this person may be contacted in an emergency in case I am unable to be reached
Is this person NOT permitted to Pick Up your student? [6]

Yes, this person is NOT permitted to Pick Up my student