Identification and Emergency Information

Step 1 of 2

To Be Completed by Parent or Authorized Representative

Child's Name

First Middle Last

Child's Gender(Required)

Parent / Guardian Phone Number(Required)

Child's Residential Address(Required)

Street Address City State ZIP Code

Child's Birthdate(Required)

Parent / Guardian Name(Required)

First Middle Last

Parent / Guardian Phone Number(Required)

Parent / Guardian Address

Street Address City State ZIP Code

Parent / Guardian Home Phone Number(Required)

Do you need to add a Parent / Authorized Representative?(Required)

Yes

Parent / Guardian Name(Required)

First Middle Last

Parent / Guardian Phone Number(Required)

Parent / Guardian Home Address(Required)

Street Address City State ZIP Code

PERSON RESPONSIBLE FOR CHILD

First Last

HOME TELEPHONE(Required)

BUSINESS TELEPHONE(Required)

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

Person 1

NAME(Required)

First Last

ADDRESS(Required)

Street Address City State ZIP Code

TELEPHONE(Required)

RELATIONSHIP(Required)

Person 2

NAME

First Last

ADDRESS

Street Address City State ZIP Code

TELEPHONE

RELATIONSHIP

Person 3

NAME

First Last

ADDRESS

Street Address City State ZIP Code

TELEPHONE

RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

PHYSICIAN(Required)

DENTIST(Required)

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?(Required)

CALL EMERGENCY HOSPITAL

Other

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE *

Person 1

NAME(Required)

First Last

RELATIONSHIP

Person 2

NAME

First Last

RELATIONSHIP

Person 3

NAME

First Last

RELATIONSHIP

TIME CHILD WILL BE PICKED UP(Required)

Parent / Guardian Email

DATE(Required)

Parent / Guardian Signature(Required)

CAPTCHA

This field is for validation purposes and should be left unchanged.

Identification and Emergency Information

To Be Completed by Parent or Authorized Representative

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

Person 1

Person 2

Person 3

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

Person 1

Person 2

Person 3

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