Holy Trinity Roman Catholic

Separate School Division

502 Sixth Avenue North East

Moose Jaw, SK S6H 4P8

Sample Form

Emergency Plan

Name: ___________________________________ Date: _____________________

Child-specific emergencies:

IF YOU SEE THIS: DO THIS:

If an emergency occurs:

1. Stay with the child

2. Call or designate someone to call the school-based emergency contact person

· State who you are

· State where you are

· State the problem

· In cases where a student has been asked to call the emergency contact person, ask the student to come back and confirm the contact.

3. The emergency contact person will assess the child and decide whether the emergency plan should be implemented.

4. If the emergency contact person is unavailable, the following staff members are trained to initiate the emergency plan:

___________________________________________

___________________________________________

Date: ___________________________________________

Parent Signature: ___________________________________________

School Administrator Signature: __________________________________