Afterschool Childcare Emergency Contact Form
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1Afterschool Childcare
Emergency Contact Form
:
Date
Parent / Guardian Information
Mother (Guardian):
First/Last name:
Address:
Email address:
Home Phone:_______________ Cell Phone:
Work:
Phone:__________________
Place of employment:
Father (Guardian):
First/Last name:
Address:
Email address:
Home Phone:_______________ Cell Phone:
Work:
Phone:__________________
Place of employment:
Emergency contact(s) for after school hours:
First/Last name:
:
:
:
Home Phone
Cell Phone
Work Phone
:
Relationship to child
First/Last name:
:
:
:
Home Phone
Cell Phone
Work Phone
:
Relationship to child
Approved people for pickup:
Individuals not listed will be unable to take children without phone authorization from parent/guardian.
Please keep this updated.
_______________________________________________________
_______________________________________________________
_______________________________________________________
❏ I give authorization for my child’s medical records to be copied and filed in the child care classroom.
Parent/Guradian Signature
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