SHA Emergency Release Form

Emergency Release Form

Please provide important health (and other) information needed for SHA Chaperones, as well as any other care requirements for the student.
STUDENT INFORMATION
Type of Emergency:*
If other, please explain in notes below.
Student Name *

First NameLast Name
Student's DOB*

MonthDayYear
Date
Student US Phone Number or WhatsApp
SHA uses WhatsApp to communicate with Students who have international phone #s. If the student does not have a US phone number or WhatsApp, please provide the best way to contact the student.
Student Email *
example@example.com
Student Pronouns*
Does the student have any preexisting conditions that we need to know about?*
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Phone number to call when we arrive at School to pick up the Student*
Please enter a valid phone number.
Pickup Instructions for SHA Driver*
Example: Call Health Center when driver arrives
SCHOOL INFORMATION
Attending School*
School Contact Name*
School Contact Email*
example@example.com
Health Center Contact Phone Number*
Please enter a valid phone number.
Details for Emergency Pickup
Pickup Date *

MonthDayYear
Date
Expected Date to Return to Campus*

MonthDayYear
Date
What is the Student's current (or last) temperature, and what time was the temperature taken?*
What other symptoms is the Student experiencing? Please list all symptoms reported or observed.*
Will the Student be bringing any medications with them? If YES, please list medications and dosage instructions in field below.*

YESNO
Please list all medications the student has taken in the last 12 hours and/or will be bringing with them, along with dosage instructions. If the student has not taken (or is not bringing) any medications, write "NONE" below. *
*Place all medications in sealed bag to be handed to driver who will give to SHA Chaperone upon arrival at hotel. Students are not permitted to have any medications in their room. Chaperones carry standard OTC medications and will hold all other medications to administer to students as directed.
Does the Student require any additional care or specific attention to their medical condition? Please describe. If not medical condition, please write NA or NONE.*
Please describe the student's current mental health state or situation.*

Student has vocalized or has indicated plans for suicideStudent is cutting, or has exhibited self-harm behaviorStudent is experiencing anxiety or stressStudent is stable, but needs to be off campus for a "mental health break" per the school's requirements.Other
Please describe any other details SHA should know about the student's current or pre-existing condition(s) that may apply to their care needs going forward. *
An assessment of the student by the SCHOOL is required before we can accept guardianship of the student for a mental health-related issue. Please upload a copy of the assessment performed by a certified School Counselor or Therapist.*

Cancelof
Will the student require a negative COVID test to return to campus?*
If YES, SHA Chaperones will administer the test by 9am on the date specified below and report the result to the School and Parents.
If yes, please provide the specific date the test will need to be performed by SHA staff

MonthDayYear
Date
Will the SCHOOL administer their own COVID test upon return to campus?*
If YES, please explain your school's protocol for students who test positive upon return. Will they go back to SHA, or another destination, etc?
Please explain in detail your school's COVID Quarantine protocol for the campus, or any specific care required for this student. If COVID+, please include the specific timeline (including test dates) the student must follow to return to campus.*
Ex: 5-Day isolation. Rapid COVID test on Day 5. Return to School on Day 6 if negative
Please list any allergies the student has (if any) below. If no allergies, write "NONE" *
If student uses SHA Transportation for their return to campus, what drop off instructions should we provide to the driver? If drop off at campus is not needed, please list "NONE" or add any additional instructions.*
Does the student need to check in, or be dropped off to another responsible party at the school?
Student Insurance Card (attach file or image here)*

Cancelof
SHA Preparation List - Please check off each item to ensure your student is prepared for their stay with SHA.*

"SHA Explore" App is Downloaded to Student's PhoneWhatsApp is Downloaded to Student's PhoneMultiple Days of ClothingAll Necessary ToiletriesTechnology Devices & ChargersAll Required School Work
If you have any changes or additional information for the student you can contact us anytime at 844-742-2255

We will be there soon!
Should be Empty:

Emergency Release Form

*Place all medications in sealed bag to be handed to driver who will give to SHA Chaperone upon arrival at hotel. Students are not permitted to have any medications in their room. Chaperones carry standard OTC medications and will hold all other medications to administer to students as directed.