Emergency Contact Form (Page 2 of 2) in pdf

ROOKIE ROCKETS CHILD CARE---(SUMMER)

emergency contact form

Child Name_________________________________ Grade just completed_________ Birthdate___________

Address__________________________________________________ Home phone____________________

E-mail Address___________________________________________________________________________

Mother’s name______________________________________ Cell phone___________________ text Yes No

Work place_______________________________________________ Work phone____________________

Father’s name______________________________________ Cell phone___________________ text Yes No

Work place______________________________________________ Work phone____________________

Emergency contact (other than parent)___________________________________________________________

Relationship to child________________________________________ Phone___________________________

Any health concerns/ medications______________________________________________________________

_________________________________________________________________________________________

________________________________________________________________________________________

These people have my/our permission to pick-up my/our child/children from the Rookie Rockets Child Care,

with or without a note from me/us.

Name________________________________________ Relationship to child________________________

Name________________________________________ Relationship to child_________________________

Parent Signature_________________________________________________ Date_____________________

Emergency Contact Form Page 2