Preschool Emergency Form And Information printable pdf download

Preschool Emergency Form And Information

PRESCHOOL EMERGENCY FORM AND INFORMATION

PLEASE FILL OUT AND GIVE YOUR CHILD'S INSTRUCTOR. PLEASE PRINT

LAST NAME___________________________________FIRST NAME________________________

ADDRESS_________________________________________________________________________

HOME PHONE_________________________________BIRTHDAY__________________________

MOTHER'S NAME______________________________HOME PHONE_______________________

MOM'S CELL PHONE ___________________________

MOTHER'S EMPLOYMENT & PHONE:_________________________________________________

FATHER'S NAME_______________________________HOME PHONE_______________________

FATHER'S CELL PHONE ________________________

FATHER'S EMPLOYMENT & PHONE:_________________________________________________

BROTHERS OR SISTERS_______________________________AGE____________

_______________________________AGE____________

NAMES & PHONE NUMBERS IN CASE OF EMERGENCY (WE CALL PARENTS FIRST)

1._________________________________________________________________________________

2._________________________________________________________________________________

3._________________________________________________________________________________

ALLERGIES:_______________________________________________________________________

MEDICATION TAKEN:______________________________________________________________

IF YOU OR YOUR EMERGENCY CONTACTS CANNOT BE REACHED IN AN EMERGENCY,

AND IF IN THE JUDGEMENT OF THE PRESCHOOL STAFF IMMEDIATE MEDICAL AND/OR

HOSPITAL ATTENTION IS NEEDED, DO YOU AUTHORIZE RESPONSIBLE PARK DISTRICT

STAFF TO SEND YOUR CHILD (PROPERLY ACCOMPANIED) TO AN AVAILABLE HOSPITAL

OR PHYSICIAN?

YES_____

NO_____ (911 WILL BE CALLED FIRST IF NECESSARY)

PARENT

SIGNATURE_______________________________________________DATE___________________

Preschool Emergency Form And Information