AUTHORIZATION TO RELEASE STUDENT IN AN EMERGENCY

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AUTHORIZATION TO RELEASE STUDENT IN AN EMERGENCY

Parents/Guardians:

Please enter information below that is needed for your child in the event of an emergency. Please complete and return immediately. This vital information will help us care for your child’s safety to the best of our ability.

* Indicates required question

Email *

Your email

Student Information

One form per child.

Student’s Last Name *

Your answer

Student’s First Name *

Your answer

Student Gender *

Female

Male

Prefer not to say

Other:

Birthdate *

MM

/

DD

/

YYYY

Age *

10

11

12

13

14

15

Other:

Grade *

6

7

8

House Number and Street Address *

Your answer

City and State: *

Lexington, KY

Other:

Zip Code *

Your answer

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