Emergency Contact Form

Child's Name*
First Last
Child's Birthday*
MM slash DD slash YYYY
Child's Address*
Street Address Address Line 2 City State ZIP Code
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Primary Legal Guardian 1
First Last
Guardian 1 Relationship to Child*
Guardian 1 Address is same as child*
- The above is correct
Guardian 1's Address*
Street Address Address Line 2 City State ZIP Code
Guardian 1's Phone*
Guardian 1's Email
Does Guardian 1 Have a Place of Business
- No
Guardian 1's Place of Business Name*
Guardian 1 Business Address*
Guardian 1 Business Phone*
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Legal Guardian 2
First Last
Guardian 2 Relationship to Child
Guardian 2 Address is same as child
- Yes
Guardian 2 Address
Street Address Address Line 2 City State ZIP Code
Guardian 2 Phone
Guardian 2 Email
Does Guardian 2 Have a Place of Business
- No
Guardian 2 Business Name
Guardian 2 Business Phone
Guardian 2 Business Address
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Emergency Contact 1*
First Last
Emergency Contact 1 Phone*
Emergency Contact 2
First Last
Emergency Contact 2 Phone
Emergency Contact 3 Name
First Last
Emergency Contact 3 Phone
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Additional Release
- ONLY release my child to Legal Guardian
Additional Release Name 1*
First Last
Additional Release 1 Address*
Street Address Address Line 2 City State ZIP Code
Additional Release 1 Phone*
- I don't need any additional releases
Additional Release 2 Name*
First Last
Additional Release 2 Address*
Street Address Address Line 2 City State ZIP Code
Additional Release 2 Phone*
- I am done entering releases
Additional Release 3 Name*
First Last
Additional Release 3 Address*
Street Address Address Line 2 City State ZIP Code
Additional Release 3 Phone*
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Name of Child's Physician or Medical Providor*
Medical Provider Phone*
Medical Provider Address*
Street Address Address Line 2 City State ZIP Code
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Does the child have any disabilities? If yes, please write them:*
List all allergies including medical reactions*
Please list all medication and dietary information necessary in an emergency situation*
Please list all medications and special conditions*
Please list all additional information on special needs of a child*
Health Insurance Carrier*
Policy Number*

This must be correct
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Signature to consent for obtaining emergency medical care*
Signature to consent for administering first aid*
Signature to consent for walking field trips*
Signature to consent for transportation from the facility*

Emergency Contact Form

Emergency Contact Form

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