Kipp Academy Elementary Family Pick-up Contact Form

PICK UP/ ACCESS INFORMATION STUDENT INFO Name (Last)

(First)

(Middle)

Email Address where we can reach you: __________________________________________________________

AUTHORIZED PERSONS FOR EARLY DISMISSAL In the event of an early dismissal, parents/guardians or the following individuals are authorized to sign them out:

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

PERSONS WITH RESTRICTED ACCESS TO STUDENTS Name

Relationship

Notes

Name

Relationship

Notes

SUMMER SCHOOL PICK UP Who will be picking up your child from Summer School?

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

SCHOOL YEAR PICK UP Who will be picking up your child from school during the year?

Name

Relationship

Phone

Name

Relationship

Phone

[PLEASE INFORM KIPP ACADEMY ELEMENTARY OF ANY CHANGES TO THE ABOVE LISTS]

PLEASE TURN OVER

Please update this information if necessary PARENT/GUARDIAN 1:

PARENT/GUARDIAN 2:

relationship

Name

____

Home #

______ Cell #

Work/Cell #

_____ First Contact: Home Cell Work

Email Address

__________

_____

relationship

Name Home #

______ Cell #

______

Work#:_________________ First Contact: Home Cell Work Email Address

Mailing Address:

Mailing Address:

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

Parent/Guardian 1 Primary Contact for Messages and Mailings

Parent/Guardian 2 Primary Contact for Messages and Mailings

In case of an emergency and we are not able to reach either parent/guardian, please list TWO (2) other contacts: Name Name

Relationship

Phone

Relationship

Phone

(Please do not forget to let the above persons know they are emergency contacts)