Emergency Contact Information and Pick Up Authorization - To be completed by parent/guardian
Please ensure your contact information (phone number and email address)  in Infinite Campus are correct.  This form is for Authorizing Pick-Up in case of an emergency.
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Email *
Student LAST Name *
Student FIRST Name *
Grade Level *
Pick-Up Authorization
In case of an emergency, accident, or serious illness of the above-named child, I request the school contact me (primary guardian).  If school personnel are unable to contact me,  I hereby authorize them to call the following people who are authorized to pick up my child from school or a school-sponsored activity.
Emergency Contact Name #1 *
Emergency Contact Relationship #1 *
Emergency Contact Phone Number #1 *
Emergency Contact Name #2
Emergency Contact Relationship #2
Emergency Contact Phone Number #2
Emergency Contact Name #3
Emergency Contact Relationship #3
Emergency Contact Phone Number #3
You will now sign by typing your name below.  This will take the place of physically signing the form and returning it to Leestown.  
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