Pre-Emergency Evacuation Release Form
Your Student’s Teacher________________________________
Student’s Name: _______________________ __________________________ Birth Date ___________________
Last Name First Name
Home Address ___________________________________________________ Home Phone ________________
List the names of any sibling(s) that also attends this school:
Name____________________________________________ Teacher______________________
Name____________________________________________ Teacher______________________
List guardians who are permitted to pick up student in an emergency:
Father’s Name___________________________________ Alternate Phone #’s _____________________________
Mother’s Name __________________________________Alternate Phone #’s _____________________________
Guardian's Name ________________________________ Alternate Phone #’s _____________________________
Parent or Own Guardian: Is student her/his own legal guardian: Yes No
Parent: If we must evacuate the school & leaving is considered safe by authorities, can your student be released to
make their way home on their own? Yes No
Please list the names of other people authorized to pick up, transport, and care for your student in the case of personal emergency
or a community disaster. Please list as many people as possible. They need to bring identification.
N
ON-GUARDIAN STUDENTS WILL ONLY BE RELEASED TO SOMEONE AGE 18 OR O
LDER
.
Name Address Phone Number(s) Relationship .
_____________________ _______________________ __________ __________ ________________
_____________________ _______________________ __________ __________ ________________
_____________________ _______________________ __________ __________ ________________
_____________________ _______________________ __________ __________ ________________
_____________________ _______________________ __________ __________ ________________
_____________________ _______________________ __________ __________ ________________
The following information could be vital to emergency medical care personnel in the case of a community disaster.
Student’s doctor or medical group___________________________________________________ Phone__________________
Does your student have any chronic illnesses or allergies/asthma? □ No □ Yes (Please Explain Below)
______________________________________________________________________________________________________
Is your student allergic to any medication(s)? List: _____________________________________________________________
Is your student presently taking any medication? List: __________________________________________________________
______________________________________________________________________________________________________
Other concerns? _________________________________________________________________________________________
I hereby authorize VISTA EDUCATION CAMPUS POST-HIGH PROGRAMS to release my student to any of the above
persons, if I am not available. The person picking up the student must have picture identification.
PARENT/GUARDIAN SIGNATURE: _________________________________________DATE:____________
DO NOT WRITE BELOW THIS LINE
Signature of Adult Staff releasing student_____________________________________________ Date: _____________
Signature of Authorized Adult taking student__________________________________________ Date: _____________
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