25-26 EMERGENCY STUDENT DATA FORM

School Name*

I.D. No.*

Grade*

Student's Last Name*

First Name*

Middle Name*

Address*

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

Registering Parent/Guardian's 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

Military 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 of Emergency Contact 1*

Address of Emergency Contact 1*

Relation to Student - Emergency Contact 1*

Phone at Work - Emergency Contact 1*

Name of Emergency Contact 2*

Relation to Student - Emergency Contact 2*

Address of Emergency Contact 2*

Phone at Work - Emergency Contact 2*

Family Doctor*

Family Doctor Phone*

Preference of Hospital*

Phone of Preferred Hospital*

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. Any person verified as a parent above and in the District’s Student Information System is presumed to be authorized to pick up the student unless otherwise indicated.

Authorized 1

Authorized 2

Authorized 3

Authorized 4

Authorized 5

Authorized 6

Not authorized 1

Not authorized 2

Not authorized 3

Not authorized 4

Not authorized 5

Not authorized 6

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*

Signature*

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 name of any individual who is authorized or unauthorized by the registering parent to pick up a student from school must be contained on the Emergency Student Data Form for that student to be released to the individual by school staff (See Fla. Stat. 1000.21(5) and Policy 0100 for definitions of “parent” The school shall abide by the information provided on the Emergency Student Data Form. Any person verified as a parent in the District’s Student Information System is presumed to be authorized to pick up the student unless otherwise indicated. The registering parent who completes the Emergency Student Data Form is responsible for providing information that is truthful and accurate – and in the case of unmarried, divorced, or separated parents, consistent with any court order in effect governing their divorce, separation, or parenting matters. Any parent contesting the information provided in the Emergency Student Data Form by another parent may seek assistance from the court governing their parenting matters to compel the registering

parent to revise the information. School staff shall provide such persons with the website for the Family Court Self-Help Program at http://www.jud11.flcourts.org/Family-Court-

Self-Help-Program. Parents may also agree to change the registering parent and submit an Agreement to Change Registering Parent Form (FM-7600) at any time. FM-2733E Rev. (07-22)