Disaster Release Form

Emergency and Disaster Release Form

Emergency and Disaster Preparedness Student Release Procedures

In the event of an emergency/disaster, your children will remain at their school until you or the person designated by your signature comes to the school and personally signs your child out, for up to 72 hours. After 72 hours, your child may be transferred to the nearest Red Cross Shelter. NOTE: These are the only conditions under which your child can be released by school personnel. To be certain that we know when the child is released and that the emergency is handled in a calm, orderly way, we ask that you complete the lower portion of this letter which contains the Disaster Release Form. PARENTS, BE SURE TO SIGN BELOW IN THE SPACE FOR PARENT SIGNATURE.
Disaster Release Form

(Please, fill out one form per family)
Student’s Information:
Last Name First Name Grade Teacher
Student’s Information:
Last Name First Name Grade Teacher
Student’s Information:
Last Name First Name Grade Teacher
Student’s Information:
Last Name First Name Grade Teacher
Address
Street Address City State / Province / Region ZIP / Postal Code
Mother’s Information:
Name (H)Phone (W)Phone (C)Phone
Father’s Information:
Name (H)Phone (W)Phone (C)Phone
I designate that my children may be released to the following three people in case of emergency/disaster:
Name Phone (H) Phone (W) Phone (C)
I authorize release of my son(s)/daughter(s) to any adult with whom he/she feels comfortable
- Yes
- No
Medical Alert:
Student Condition Medication
Parent Signature
Parent Name
This student was /These students were released to __________by________(School Release Team Member) on_____________(Date)_______________at ________(Time)______.
Student/s released to
(Signature of authorized adult)
Authorized adult name
Date
Date Format: MM slash DD slash YYYY

Imagination School

Disaster Release Form

Emergency and Disaster Release Form

Emergency and Disaster Preparedness Student Release Procedures

Disaster Release Form

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Last Name	First Name	Grade	Teacher

Last Name	First Name	Grade	Teacher

Last Name	First Name	Grade	Teacher

Last Name	First Name	Grade	Teacher