• WASHINGTON SCHOOL EMERGENCY FORM - 2019 - 2020        Homeroom_______

    Child’s Legal Name____________________________Homeroom Teacher_____________________

    Home Language______________

    Date of Birth________________Sex_________

    Address________________________________Zip Code___________



    Cell Phone:___________________Email Address______________________________

    Bus Stop____________________Bus In________Bus Out_________Walker_______

    Picked up and dropped off by________________________Phone__________________

    In case emergency, illness or accident when the parent/guardian cannot be reached, the school is authorized to contact the following to pick up or assist my child:

    You must complete the section below:        

    Name________________________  Ph.#______________________  Relationship_________________

    Name____________________________ Ph.#_________________________  Relationship____________________

    Name____________________________ Ph.#_________________________  Relationship____________________

    The Washington School cannot release your child to anyone other than those listed above without written permission from a parent/guardian.

    Does your child have siblings attending the Washington School?        Yes_____ No_____

    Name and grade of brothers/sisters_______________________________________________________

    The School Department offers free vision and hearing screening. Do you give permission for your child to have a free hearing and vision test?                                      Yes_____ No_____

    The Washington School takes many school field trips to various museums, theaters, & recreational sites. Does your child have permission to attend field trips?              Yes_____            No_____

    Your child may be photographed and/or videotaped by the media or school personnel during school events. Do you give permission for photos/videos to be put on school website/social media.   Yes_____           No_____

    Does your child have any restrictions concerning custody/restraining orders?      Yes_____ No_____

    (Please send a copy of custody arrangements/restraining orders to school)

    Does your child see a counselor? Yes___ No___Counselor’s name_____________________Agency__________

    Should your child have a crisis in school do you give permission to have your child speak with the Washington School Social Worker?   Yes_____ No_____

    Do you give the school staff permission to speak with your child’s doctor/s? Yes______ No______

    I support the Code of Respectful Behavior and the School/Family Compact   Yes_______ No______

    Signature of Parent/Guardian___________________________________Date____________

    (Please complete the medical information on the reverse side)