Emergency Contact Information Form printable pdf download

Emergency Contact Information Form

Asbury Child Development Center

Emergency Contact Information

School Year:______________

Start Date: ____________

Child’s First name

Middle

Last

Birthdate:__________________________________

Sex: M______ F ______

Home

address:_____________________________________________________________________________

Street

City

Zip code

Child lives with:

Both parents

Mother

Father

Other

1st person to contact in case of an emergency

Name _____________________________Relationship:______________________________

Best phone number for contact: _______________________________________

Alternate number/e-mail for contact:

_______________________________________

Employment ______________________________

Work Number: ___________________________

2nd person to contact in case of emergency

Name _____________________________

Relationship:______________________________

Best phone number for contact: _______________________________________

Alternate number /e-mail for contact:

_______________________________________

Employment ______________________________

Work Number: ___________________________

Authorized persons to pick up other than parents:

(If you need more room please use the back of this form or attach the list to this form.)

1. _____________________________________________________________________________

Name

Address

Phone

relationship

2. ______________________________________________________________________________

Name

Address

Phone

relationship

3. ______________________________________________________________________________

Name

Address

Phone

relationship

Food and Drug Allergies:______________________________________________________________

Any medical conditions we should be aware of:

________________________________________________

Emergency Contact Information Form

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