Emergency Information Form

Emergency Information Form

Please fill out the below Emergency Information as part of your enrollment package.
  • Please enter your child's name.
  • Please enter your child's birth date.
  • Please enter any allergies that your child has. Please enter "None" if he/she doesn't have any.
  • 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.
  • Please enter your primary address, including apartment number if appropriate.
  • Please provide us your home, or primary, phone number where we can contact you in case of an emergency.
  • Please provide us the child's mother's name or if there isn't a mother, please enter N/A.
  • Please provide us the mother's work phone.
  • Please provide us the mother's cell phone.
  • Please provide us an email address where we can send emails to the child's mother.
  • Please provide us the child's father's name or if there isn't a father, please enter N/A.
  • Please provide us the father's work phone number.
  • Please provide us the father's cell phone number.
  • Please provide us the father's email address where we can send emails to the child's father.
  • Please provide us the name, relationship to the child and phone number(s) of an emergency contact if the parents can't be contacted.
  • What is the relationship to the child of the emergency contact.
  • Please provide us the emergency contact's phone number.
  • Please provide us the name, relationship to the child and phone number(s) of an emergency contact if the parents can't be contacted.
  • What is the relationship to the child of the emergency contact.
  • Please provide us the emergency contact's phone number.
  • Please provide us the name, relationship to the child and phone number(s) of an emergency contact if the parents can't be contacted.
  • What is the relationship to the child of the emergency contact.
  • Please provide us the emergency contact's phone number.
  • Please provide us with the name of the child's primary care physician.
  • Please provide us the phone number of your child's primary care physician.
  • 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.
  • Please enter your name as the primary guardian of your child to authorize the use of the emergency contact information or emergency treatment.
  • Please enter your name in lieu of a signature to authorize the use of the emergency information.
  • Please enter today's date.
  • Please provide us with your email address in order for us to more efficiently communicate with you.

You are https://es.medadvice.net/nulaslim required to complete работа this form as part of the enrollment package.

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