Emergency Information Form -

Emergency Information Form

Please fill out the below Emergency Information as part of your enrollment package.

Child's Name*
First Last

Please enter your child's name.
Your Child's Birth Date*

Please enter your child's birth date.
Allergies*
Please enter any allergies that your child has. Please enter "None" if he/she doesn't have any.
Any Medical Conditions*
Please let us know of any medical conditions that your child has. Please enter "None" if he/she doesn't suffer from any medical conditions.
Address*
Street Address Address Line 2 City State ZIP Code

Please enter your primary address, including apartment number if appropriate.
Home Phone
Please provide us your home, or primary, phone number where we can contact you in case of an emergency.
Mother's Name:*
First Last

Please provide us the child's mother's name or if there isn't a mother, please enter N/A.
Mother's Work Phone
Please provide us the mother's work phone.
Mother's Cell Phone
Please provide us the mother's cell phone.
Mother's Email
Enter Email Confirm Email

Please provide us an email address where we can send emails to the child's mother.
Father's Name*
First Last

Please provide us the child's father's name or if there isn't a father, please enter N/A.
Father's Work Phone
Please provide us the father's work phone number.
Father's Cell Phone
Please provide us the father's cell phone number.
Father's Email

Please provide us the father's email address where we can send emails to the child's father.
Person call if parents are unavailable*
First Last

Please provide us the name, relationship to the child and phone number(s) of an emergency contact if the parents can't be contacted.
Emergency Contact's relationship to the child.*
What is the relationship to the child of the emergency contact.
Emergency Contact's Phone Number*
Please provide us the emergency contact's phone number.
Person call if parents are unavailable
First Last

Please provide us the name, relationship to the child and phone number(s) of an emergency contact if the parents can't be contacted.
Emergency Contact's relationship to the child.
What is the relationship to the child of the emergency contact.
Emergency Contact's Phone Number
Please provide us the emergency contact's phone number.
Person call if parents are unavailable
First Last

Please provide us the name, relationship to the child and phone number(s) of an emergency contact if the parents can't be contacted.
Emergency Contact's relationship to the child.
What is the relationship to the child of the emergency contact.
Emergency Contact's Phone Number
Please provide us the emergency contact's phone number.
Child's Physician*
First Last

Please provide us with the name of the child's primary care physician.
Physician's Phone Number*
Please provide us the phone number of your child's primary care physician.
Parental Release
In case of an emergency and the above can't be reached, I hereby give permission to the staff of All Saints Child Care Center to authorize emergency treatment for my child.
Parent's Name*
First Last

Please enter your name as the primary guardian of your child to authorize the use of the emergency contact information or emergency treatment.
Parent's Signature*
Please enter your name in lieu of a signature to authorize the use of the emergency information.
Today's Date*

Please enter today's date.
Your Email

Please provide us with your email address in order for us to more efficiently communicate with you.

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