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SELP Emergency Contacts and Authorized Pick-Ups Form - 2023-24
Identify the adults who can be contacted in the event of an emergency and those authorized to pick up the scholar.
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Email
*
Your email
1. Today's Date
*
MM
/
DD
/
YYYY
2. Scholar's Last Name
*
Please type the name of the program participant below.
Your answer
3. Scholar's First Name
*
Please type the name of the program participant below.
Your answer
4. Scholar's Home Address
*
Your answer
5. Scholar's Grade Level
*
K
1
2
3
4
5
6
7
8
6. Scholar's Birth Date
*
MM
/
DD
/
YYYY
7. Scholar's Age
Your answer
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