Emergency Release Form | She Elevates

STUDENT NAME*

STUDENT AGE*

STUDENT DOB*

STUDENT GRADE AT SCHOOL*

PARENT/GUARDIAN NAME*

First Last

RELATIONSHIP TO STUDENT*

PARENT/GUARDIAN ADDRESS*

Street Address Address Line 2 City State ZIP Code

PARENT/GUARDIAN EMAIL*

Enter Email Confirm Email

EMERGENCY PHONE*

(CELL/WORK/HOME)

ALTERNATE PHONE*

(CELL/WORK/HOME)

PARENT/GUARDIAN 2 NAME

First Last

RELATIONSHIP TO STUDENT

PARENT/GUARDIAN 2 ADDRESS

Street Address Address Line 2 City State ZIP Code

PARENT/GUARDIAN 2 EMAIL

Enter Email Confirm Email

EMERGENCY PHONE 2

(CELL/WORK/HOME)

ALTERNATE PHONE 2

(CELL/WORK/HOME)

PRIMARY CARE PHYSICIAN*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

ARE THERE ANY MEDICAL CONDITIONS OF WHICH WE SHOULD BE MADE AWARE?

BY SIGNING THIS FORM, I AM AUTHORIZING SHE ELEVATES, IN THE EVENT OF AN EMERGENCY WHERE I CANNOT BE CONTACTED, TO SECURE WHATEVER MEDICAL CARE IS NECESSARY FOR THE SAFETY OF MY STUDENT. I WILL ASSUME ALL COSTS INCURRED FOR EMERGENCY CARE.

Parent/Guardian Signature*

By typing my name above I am authorizing this entry to be used as my electronic signature.

Date

Phone

This field is for validation purposes and should be left unchanged.