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 required to complete this form as part of the enrollment package.

Upcoming Events

There are no upcoming events.

View Calendar

Facebook
Search