Student Emergency Release Form

Student / Teacher Information

Please select the program you're applying for*

* = Required Field

Student's Name*

First Last

Student's Grade*

Parental Email

Parent / Guardian Email*

After this form is submitted we will send you an email notification.

Parent / Guardian #1 Contact Information

Parent / Guardian's Name (#1)*

First Last

Daytime Contact Number*

Night Time Contact Number

Cell Phone

Parent / Guardian #2 Contact Information

Parent / Guardian's Name (#2)

First Last

Daytime Contact Number

Night Time Contact Number

Cell Phone

Medical Information

Describe any medical conditions:

Allergies:

Medications:

Emergency Contacts

(at least one should live locally if possible.)

Name*

Phone*

Relationship to Child*

Name

Phone

Relationship to Child

Name

Phone

Relationship to Child

Out of Province Contacts

Name

Phone

Relationship to Child

Name

Phone

Relationship to Child

Confirmation

In case of an emergency I grant Navigate-NIDES permission to release my son or daughter into the care/guardianship of any of the above name people.

Confirmation*

I agree

Signature*

Name

This field is for validation purposes and should be left unchanged.