Emergency Contact Form 2022-2023
Scottsdale Country Day School

STUDENT INFORMATION

 Last Name (Legal)
 First Name (Legal)
 Nickname
 Grade






Primary Address:
 Street
 City
 Zip Code

FAMILY INFORMATION

 Child lives with:



 Parent/Guardian 1
 
 Cellular Phone
 () -
 Email
 



 Parent/Guardian 2
 
 Cellular Phone
 () -
 Email
 

AUTHORIZED CONTACTS FOR PICK UP

Please provide contact information for persons authorized to pick your child up, or call during an emergency, if a parent can not be reached.

 Name
 
 Relationship
 
 Cellular Phone
 () -


 Name
 
 Relationship
 
 Cellular Phone
 () -


 Name
 
 Relationship
 
 Cellular Phone
 () -


SECURITY ALERTS

I wish to add Security Alerts: Yes | No

Please provide the names of anyone who is legally not permitted to pick up your child from school. Please provide the office with a copy of any court ordered documents.

PARENT/GUARDIAN AUTHORIZATION

I understand that it is the responsibility for the parent/guardian to contact SCDS immediately, in writing, if there is a change in any of the above information. A new form may be requested of me to fill out. I understand that the school policy is to show an SCDS decal to identify individuals who are permitted to pick up my child(ren). This form is to provide information to SCDS in case a decal is not presented at pick up or in case of an emergency. Please note that anyone without a decal or a 4 digit sign in/out code may be asked to provide photo ID.

By checking this box and entering my name in the box below, I am agreeing that this is the equivalent of a written signature.

 
 Signed
 Aug 18, 2022
 Date


10460 N. 56th St., Scottsdale, AZ 85253       Tel: 480-452-5777       info@scdsaz.com        www.scdsaz.com