Emergency Alternate Contact

Date
MM slash DD slash YYYY
Student's Name*
First Last
Parent's Name*
First Last
Email*
In the event that the staff at HSPK is unable to reach either parent in an emergency, you are authorized to contact, and if necessary, release my child to any of the following. I realize that every effort will be made to notify a specified person. If this cannot be done, the school policy will be to call 911 for assistance and transport my child to the hospital emergency room if deemed appropriate.
Doctor's Name*
First Last
Doctor's Phone*
Doctor's Address*
Street Address Address Line 2 City State ZIP Code
Dentist's Name*
First Last
Dentist's Phone*
Dentist's Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contacts
Relationship
Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Relationship
Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
E-signature Acknowldgment*
By checking this box, I acknowledge that I am electronically signing this document.
Typed Signature*

Emergency Contacts