Form A-17 - Parent/guardian Emergency Contact Information printable pdf download

Form A-17 - Parent/guardian Emergency Contact Information

A-17 (New 06/25/13)

ESD 113 Sound to Harbor Head Start/ECEAP

Parent/Guardian Emergency Contact Information

The following information is requested in order to be used in the event of an emergency. Please provide only

as much information as you believe to be appropriate or necessary.

PLEASE PRINT all information:

Parent/Guardian Name:

Enrolled Child’s Name: ________ _______ Teacher’s Name:

Home Address: _

Home Phone: _______ Cell Phone: _______

Person/s to be notified in case of an emergency:

Name: _________________________________________________

Home Phone: ____________________ Cell Phone:

____ Work Phone: ________________

Name: _________________________________________________

Home Phone: ____________________ Cell Phone:

____ Work Phone: ________________

1. Do you have an allergy/medical problem that could result in a life‐threatening situation? ________________

If yes, describe:

2. If you are taking medication that might be useful during an emergency (i.e., Digitalis, insulin) where do you

keep it? _________________________________________________________________________________

3. Physician of 1

choice: _____________________________________________ Phone:

4. Do you authorize and direct the ESD authorities to send you to the hospital or doctor/dentist most easily

accessible? Yes  No 

5. Comments/Special Concerns:

Parent’s Signature: ______________________________________________________ Date:

NOTE to Staff: Destroy this form when the child leaves the program.

Original: Child’s File

Copies: Bus Emergency Book, Classroom Emergency Book

Forms\Admin\A-17 Parent Emergency Contact Information

Form A-17 - Parent/guardian Emergency Contact Information