Student Safety Contract Form
Please complete the Student Safety Contract Form to acknowledge and agree to the school’s safety rules and responsibilities.
Student Full Name
*
First Name
Last Name
Student Grade or Class
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
High School - Freshman
High School - Sophomore
High School - Junior
High School - Senior
Other
School or Program Name
*
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Guardian
Other
Parent/Guardian Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Contact Email
*
example@example.com
Emergency Contact Full Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Safety Rules Acknowledgment
*
I have read and agree to follow all school safety rules and guidelines. I understand the importance of safe behavior and will support the school's efforts to maintain a safe environment.
Parent/Guardian Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: