2020-2021 Student Emergency Form
Hamilton Avenue STEAM Magnet School
Sign in to Google to save your progress. Learn more
Student's Name *
Grade *
Parent/Guardian 1
Name (First and Last) *
Relationship *
Home Address *
Home Phone # *
Cell Phone # *
Work Phone # *
Email Address
Pick Up Privileges *
Parent/Guardian 2
Name (First and Last)
Relationship
Home Address
Home Phone #
Cell Phone #
Work Phone #
Email Address
Pick Up Privileges
Clear selection
Emergency Contacts
List two emergency contacts who would have permission to pick up your child and assume temporary care of your child if
you cannot be reached during an emergency. These contacts cannot be the same as parents or legal guardians, but may
include grandparents, aunts, uncles, childcare providers, friends, and neighbors that live in the local area.


Name *
Relationship *
Home Phone # *
Cell Phone # *
Work Phone #
Name
Relationship
Home Phone #
Work Phone #
By electronically signing this form, you give permission for any of the designated emergency contacts to pick up your child in case of an emergency school closure, illness, or missed bus. Should any of your emergency contact information change during the school year, please remember you need to inform the school as soon as possible. You are also providing consent for the school to share the information on this form with authorized individuals.
E-signature (Please type your name below). *
Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Greenwich Public Schools. Report Abuse
Google Forms