Emergency Contact Form Page 4
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4EMERGENCY CONTACT FORM
MY CHILD’S DOCTORS ARE
1. First/Last Name:
Specialy (e.g., pediatrics):
Address:
Work Phone:
Cell:
2. First/Last Name:
Specialy (e.g., pediatrics):
Address:
Work Phone:
Cell:
3. First/Last Name:
Specialy (e.g., pediatrics):
Address:
Work Phone:
Cell:
Other important information or instructions:
I grant permission for the caregiver program to provide or arrange for medical treatment and/or
transportation to an evacuation site and/or medical facility for my child, identified above, during an
emergency or disaster. I also grant permission for my child to be released to any of the emergency
contacts I have designated on the previous page if I am unable to pick them up in an emergency.
Printed Parent/Guardian Name:
Parent/Guardian Signature:
Date:
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