Emergency Contact and Pickup Form
Please fill out the form correctly, information will be used to ensure safe pickup!
Student Name
*
First Name
Last Name
Please upload a photo of the student.
*
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Primary Emergency Contact, Your Name
*
First Name
Last Name
Phone Number, Your Phone Number
*
Format: (000) 000-0000.
Your Relationship with the Student
*
Parent
Grandparent
Aunt/Uncle
Family Friend
Other
I understand I will be contacted in case of an emergency.
*
Yes, I understand
Please upload a photo of you or a photo of your photo ID.
*
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Secondary Emergency Contact
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Relationship with Student
*
Parent
Grandparent
Aunt/Uncle
Family Friend
Other
Can this person be contacted in case of an emergency?
*
Yes
No
Can this person pick up your student?
*
Yes
No
Please upload a photo of the person or a photo of their photo ID.
*
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Signature
*
Submit Form
Submit Form
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