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18-19 Daily & Disaster Dismissal Form

PLEASE FILL OUT ONE FORM PER STUDENT

Name of Student*

Answer Required

Home Address*

Answer Required

City*

Answer Required

ZIP Code*

Answer Required

Parent/Guardian 1 Name*

Answer Required

Parent/Guardian 1 Cell Number*

Answer Required

Parent/Guardian 1 Home Number

Answer Required

Parent/Guardian 1 Work Number

Answer Required

Parent/Guardian 2 Name

Answer Required

Parent/Guardian 2 Cell Number

Answer Required

Parent/Guardian 2 Home Number

Answer Required

Parent/Guardian 2 Work Number

Answer Required

List below the names of all the people to whom you give permission for authorized Assumption personnel to release your student to on a daily basis, as well as in the event of a disaster. Please list at least three people who would not have difficulty getting to Assumption if you were not able to.

Do not list yourself.
Do not list Assumption staff as they cannot be responsible for individual students.
Please inform those people listed below that you have done so. They should be aware that they are to come to school with a government issued identification card and pick up in the event of a disaster (earthquake, etc.). They will not receive a phone call. Please inform them of the school's student release protocol.
Tune your radio to 1610 kHz (fixed information station).

1. Name of Person*

Answer Required

Cell Phone Number*

Answer Required

2. Name of Person*

Answer Required

Cell Phone Number*

Answer Required

3. Name of Person*

Answer Required

Cell Phone Number*

Answer Required

4. Name of Person

Answer Required

Cell Phone Number

Answer Required

5. Name of Person

Answer Required

Cell Phone Number

Answer Required

Parent/Guardian 1 eSignature (type your initials please)*

Answer Required

Relationship to Student*

Answer Required

Date*

Answer Required

Parent/Guardian 2 eSignature (type your initials please)

Answer Required

Relationship to Student

Answer Required

Date

Answer Required

Thank you!