Emergency/disaster Preparedness Information - 2016-2017
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1EMERGENCY/DISASTER PREPAREDNESS INFORMATION – 2016-17
CHILD’S NAME:
_______________________________________
CHILD’S DATE OF BIRTH: _________
Parent #1 Name:
_______________________________________
Home Address :
_______________________________________
Home Phone: _______________________
Work Address:
_______________________________________
Work Phone: _______________________
Comments:
Cell Phone:
Parent #2 Name:
_______________________________________
Home Address :
_______________________________________
Home Phone: _______________________
Work Address:
_______________________________________
Work Phone: _______________________
Comments:
Cell Phone:
Emergency/Disaster Guardians (other than parents) in the IMMEDIATE VICINITY
APS
Name
Home or Work Phone
Cell Phone
Comment
Parent?
I authorize my child to be released to the above people or a staff-assigned guardian.
Parent Signature: _____________________________
Date: _____________________
Is there someone to whom your child SHOULD NOT be released?
Name: __________________________
Relationship: _______________
Comment: _________________
Name: __________________________
Relationship: _______________
Comment: _________________
Long Distance Phone Contacts (in case local emergency guardians not available)
Name
Home or Work Phone
Cell Phone
Relationship
MEDICAL INFORMATION
Child’s Doctor: ___________________________
Doctor’s Phone #: _________________________
Health Insurance Plan: ______________________
Medical Number: _________________________
Child’s Dentist: ___________________________
Dentist’s Phone #: _________________________
Serious Medical Issues – Please indicate any which apply to your child:
Convulsive disorder ____
Severe nosebleeds ____
Asthma ____
Hemophilia ____ Diabetes ____
Allergies to drugs ____
Severe food allergies _____________ Needs following medication _______________
I am sending these medications to Albany Preschool and give my permission for them to be administered as needed.
Parent Signature: _____________________________
Date: _____________________
Persons to be called if parents cannot be reached in case of medical emergency:
Name: __________________________
Phone: ____________________
Relationship _____________
Name: __________________________
Phone: ____________________
Relationship _____________
If neither parents nor persons above can be reached, we give our consent to Albany Preschool to authorize emergency medical treatment.
Parent #1 Signature:_________________________
Parent #2 Signature: _________________________
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