Parental Consent Form - Preschool At Annunciation Greek Orthodox Church (Page 2 of 4) in pdf

Parental Consent Form - Preschool At Annunciation Greek Orthodox Church Page 2

Parental Consent Form

PAGE 2

Emergency Information

Father’s Data

Mother’s Data

Name: ___________________________________

Name: ____________________________________

Home Phone: _____________________________

Home Phone: ______________________________

Cell Phone: _______________________________

Cell Phone: ________________________________

Email: ___________________________________

Email: ____________________________________

Employer Name/Address: ____________________

Employer Name/Address: _____________________

_________________________________________

__________________________________________

Work Phone: ______________________________

Work Phone: _______________________________

Emergency Contact, other than parents

Name: __________________________________________

Phone: _______________________________

Medical Contact

Physician: _______________________________________

Phone: _______________________________

Address City/State/Zip: _____________________________________________________________________

Dentist: _________________________________________

Phone: _______________________________

Address City/State/Zip: _____________________________________________________________________

Health Insurance Company Name and Policy/Identification Number: _________________________________

________________________________________________________________________________________

Other Pertinent Medical Information: __________________________________________________________

________________________________________________________________________________________

Parental Consent Form - Preschool At Annunciation Greek Orthodox Church Page 2