Emergency Contact Information

Please carefully read & submit the following for emergency contact information for your child:

CHILD CARE EMERGENCY CONTACT INFORMATION

Child's Name*
First Last
Child's Date of Birth*
MM slash DD slash YYYY
Child's Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian 1 Name*
First Last
Parent 1 Home/Cell Phone Number*
Parent 1 Work Number*
Parent 1 Email Address*
Enter Email Confirm Email
Parent 1 Home Address*
Street Address Address Line 2 City State ZIP Code
Parent 1 Place of Employment*
Parent 1 Work Title
Parent 1 Work Department
Parent 1 Work Contact Person (who usually knows your whereabouts)
Work Contact's Phone Number (for Parent 1)
Parent/Guardian 2 Name
First Last
Parent 2 Home/Cell Phone Number
Parent 2 Work Number
Parent 2 Email Address
Enter Email Confirm Email
Parent 2 Home Address
Street Address Address Line 2 City State ZIP Code
Parent 2 Place of Employment
Parent 2 Work Title
Parent 2 Work Department
Parent 2 Work Contact Person (who usually knows your whereabouts)
Parent 2 Work Contact's Phone Number
Emergency Contacts
Person to contact when attempts to reach parents are not successful.
Emergency Contact No. 1*
First Last
Emergency Contact No. 1 Home/Cell Phone #*
Emergency Contact No. 1 Work Phone
Emergency Contact No. 2*
First Last
Emergency Contact No. 2 Phone Number*
Persons (Other Than Parent/Guardian) Authorized to Pick Up the Child
We must have written permission for anyone other than parent/ guardian to pick child up from the center.
Name No. 1*
First Last
Phone*
Name No. 2
First Last
Phone
Name No. 3
First Last
Phone
Name No. 4
First Last
Phone
Child's Medical Emergency Contact
Physician's Name*
First Last
Physician's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physician's Phone #*
Dentist's Name (child's or parent's)*
First Last
Dentist's Address*
Street Address Address Line 2 City State ZIP Code
Dentist Phone Number*
Child's Health Insurance
Name of Insurance Plan*
Certificate Number (or ID) #*
Group #*
Policy Holder’s Name
First Last
Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations*
Parent/Legal Guardian Consent and Agreement for Emergencies
Parent/Guardian No. 1 Consent Agreement*
As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Parent Guardian No. 1 Electronic Signature*
First Last
Today's Date*
MM slash DD slash YYYY
Parent/Guardian No. 2 Consent Agreement
As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Parent Guardian No. 2 Electronic Signature
First Last
Today's Date
MM slash DD slash YYYY

CHILD CARE EMERGENCY CONTACT INFORMATION

Emergency Contacts

Persons (Other Than Parent/Guardian) Authorized to Pick Up the Child

Child's Medical Emergency Contact

Child's Health Insurance

Parent/Legal Guardian Consent and Agreement for Emergencies

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