Child Emergency Contact Information Form For School

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*One Form Per Child*
Emergency Contact Information
Child’s Name:______________________________________________ Birthdate: ____________________________
Emergency Contact #1: ___________________________________
Relationship to Child: ____________________
Address: _________________________________________________________________________________________
Home Phone: ____________________ Work Phone: ____________________ Cell Phone: ____________________
Emergency Contact #2: ___________________________________
Relationship to Child: ____________________
Address: _________________________________________________________________________________________
Home Phone: ____________________ Work Phone: ____________________ Cell Phone: ____________________
Emergency Contact #3: ___________________________________
Relationship to Child: ____________________
Address: _________________________________________________________________________________________
Home Phone: ____________________ Work Phone: ____________________ Cell Phone: ____________________
Emergency Contact #4: ___________________________________
Relationship to Child: ____________________
Address: _________________________________________________________________________________________
Home Phone: ____________________ Work Phone: ____________________ Cell Phone: ____________________
Authorized Pick Ups
1) ____________________________________
Phone: ______________
Attention:
2) ____________________________________
Phone: ______________
Your child will only be released to a parent, legal
guardian, emergency contact or authorized pick
3) ____________________________________
Phone: ______________
up. You may authorize as many pick ups as
4) ____________________________________
Phone: ______________
needed on an included separate sheet of paper.
Medical Information / Special Needs
Physician/Medical Provider:___________________________________________________________________________________
Address: __________________________________________________________________________
Phone:______________
Insurance:
Policy Number:
Allergies:
Medical Conditions:
Medications:
Disabilities:
Special Needs:
Restrictions:
Parental Consents - Parent Signature Required for Each Item Below
Obtaining Emergency Care:
Administering Minor First Aid Procedures
Walks & Field Trips:
Swimming / Wading:
Transportation by N4Cs:
Photograph:
Consent for Observation:
Today’s Date:
I hereby certify that the included information is accurate and complete.
Parent Signature: ___________________________________________________________
Date: ______________________
4

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