In case of Emergency FIRST CONTACTS

Custodial parent / guardians will be notified first in an emergency or for a discipline issue. This individual has pick up authority by default. Please list an alternate choice if custodial parent/guardian cannot be reached.

First Namerequired

Last Namerequired

Cell Numberrequired

Home Numberrequired

Work Numberrequired

Custodial Parent/Guardian:

First Namerequired

Last Namerequired

Cell Numberrequired

Home Numberrequired

Work Numberrequired

Relationshiprequired

Email Addressrequired

Street Addressrequired

Cityrequired

Staterequired

Ziprequired (ex. 06108 or 06108-0809)

Custodial Parent/Guardian:

FIrst Name

Last Name

Cell Number

Home Number

Work Number

Relationship

Email Address

Street Address

City

State

Zip (ex. 06108 or 06108-0809)

Child may be picked up by:

Namerequired

Phone Numberrequired

Relationshiprequired

Name

Phone Number

Relationship

Name

Phone Number

Relationship

Name

Phone Number

Relationship

Child may NOT be picked up by:

Name

Phone Number

Relationship

Name

Phone Number

Relationship

If documentation is required to be on file to prohibit certain individuals from picking up the child(ren) your are registering it must be updated each year by the parent. An option at the end of the questionnaire is available for uploading.

If you prefer, please email to ProjectShareInfo@shastacoe.org. Please include the child's name and site within the body of the email.

Medical/Miscellaneous Information

Primary Doctorrequired

Doctor Phonerequired

Primary Dentist

Dentist Phone

I hereby authorize the staff of Project SHARE to secure and sign for emergency medical care for my child at my expense, when necessary*

Yes No

Please attach the file for any documentation that needs to be on file. This must be done annually to ensure we have the most current information.

Attach File

Max file size: 10 MB

Please send a confirmation email to the address below*:

Please provide an email address where we can send a link to your current form.

Email Address :

Welcome to the Project SHARE 2023 Summer Program at the Burney Elementary School!

Student Information

In case of Emergency FIRST CONTACTS

Custodial Parent/Guardian:

Custodial Parent/Guardian:

Child may be picked up by:

Child may NOT be picked up by:

Medical/Miscellaneous Information

Welcome to the Project SHARE 2023 Summer Program at the Burney Elementary School!

Student Information

In case of Emergency *FIRST CONTACTS*

Custodial Parent/Guardian:

Custodial Parent/Guardian:

Child may be picked up by:

Child may NOT be picked up by:

Medical/Miscellaneous Information

In case of Emergency FIRST CONTACTS