Parent pick up form

Panguitch Elementary School

Panguitch, UT 84759

(435)-676-8847

Please fill out the following form if someone other than a parent/guardian will be picking up your student(s) in case of an emergency evacuation.

Student Name*

Student Grade*

Cell phone number of parent/guardian*

Parent / Guardian Email (Optional - if you would like copy of this completed form)

example@example.com

Name of person picking up student if different from parent or guardian*

Name of person picking up student if different from parent or guardian (2)

Name of person picking up student if different from parent or guardian (3)

Phone of person picking up student*

Relationship to student*

Parent Signature*