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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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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