EMERGENCY - EARLY DISMISSAL PLAN

Name of children in the family and grade          

Emergency contact #1           
   ^{Name       relationship}

              
   ^{home phone   work phone   cell phone}

Emergency contact #2           
   ^{Name       relationship}

              
   ^{home phone   work phone   cell phone}

Please put my child on the bus if transportation is provided.  Yes  No

              
Parent or Guardian Signature      Date