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LaFayette Central School District

5955 US Route 20 West LaFayette, NY 13084
315-677-9728 (p)/315-677-3372 (f)
www.lafayetteschools.org

Student Emergency Dismissal Form

STUDENT INFORMATION

Last Name*

First Name*

Middle name

Date of Birth*

PARENT / GUARDIAN INFORMATION

Parent / Guardian Name

Relationship

Date

EMERGENCY DISMISSAL INFORMATION

THIS INFORMATION IS TO BE KEPT ON FILE BY THE SCHOOL IN ACCORDANCE WITH AN AMMENDMENT TO N.Y.S. EDUCATION LAW WHICH PERMITS RELEASE OF A CHILD FROM SCHOOL ONLY TO THOSE PERSONS WHOSE NAMES APPEAR ON THE FOLLOWING LIST. ONLY LAW ENFORCEMENT OFFICIALS AND CHILD PROTECTIVE SERVICE WORKERS MAY TAKE CUSTODY OF A CHILD WITHOUT THIS PRIOR PERMISSION.

Current Signature

Parent/Guardian Signature (use mouse)

Name

Telephone

Relationship

Cell

Name

Telephone

Relationship

Cell

Name

Telephone

Relationship

Cell

In case of an emergency or change in regular dismissal procedure, the above named child may be released to the following persons(s):

Grade

ID#