Emergency Plan Form:   2020-2021 21st CCLC Schuylkill ACHIEVE AfterSchool Middle School Program
In the event that an emergency situation may occur during the Schuylkill ACHIEVE AfterSchool Program and it is necessary to dismiss students before the regular dismissal time, an emergency plan for each student is kept on file.  

The completion of the form will act as an electronic signature of the parent listed in the form.

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Email *
Student's First Name *
Student's Last Name *
Student's Grade *
Parent's First Name *
Parent's Last Name *
Emergency Contact Information:  (Name and relationship to child)
Emergency Contact Cell Phone number
Emergency Contact Work Phone number
Emergency Contact Home Phone number
Will your child go directly home after the ACHIEVE program?
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If your child is to go elsewhere, please provide details including names, addresses and phone numbers of persons to whom the student may go.
Please provide any additional specific information that will be helpful to the student and staff in case of an early dismissal.
*Please Note:
This plan will be kept on file for the school year.  Pleas notify a Schuylkill ACHIEVE AfterSchool Program Site Coordinator (Mrs. Marisa Horbal or Mrs. Courtney Schock) if any changes occur.
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