Student Release

Occasionally a student may become ill or have an accident while at school. This may necessitate contacting the guardian or seeking medical attention for the student. The information you provide below will allow us to care for your child in case of an emergency. Registration is not complete without this signed form.

Registration - Student Release

Student Name*
First Last
Student Number
Student Home Address*
Street Address Address Line 2 City State ZIP Code
Sex*
Grade*
Birthdate*
Month
Day
Year
Please list any health problems
List the phone number you would like automated calling to contact.*
Parent / Guardian Information*
Please list all parents and legal guardians.
Name (First, Last) Relationship Home Phone Work Phone Email
Valley Jr. High requires a legal guardian or a person authorized by the guardian to sign for your student to be released from school during the day. Please include individuals you authorize to pick up your child from school when you cannot be contacted. If someone who is not listed below comes to check out your student, we will not be able to release them. A non-custodial parent's name must be written below for the non-custodial parent to check this student out.
Local Emergency Contacts & Authorized Individuals*
These people are authorized to to check my student out from school. In the event that non of these individuals are available, or in the case of an emergency, the school will call an ambulance or the paramedic if it is deemed necessary.
Name (First, Last) Phone Relationship to Student
Is there information on file preventing certain individuals from checking this student out?*
- Yes
- No
By writing my name below, I understand the information provided on this form. I also accept financial responsibility for all accident/illness-related costs and I agree to the emergency and release procedures outline above.
Parent or Legal Guardian*
First Last
Relationship to Student*

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Name (First, Last)	Relationship	Home Phone	Work Phone	Email

Name (First, Last)	Phone	Relationship to Student

Registration - Student Release

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