Emergency Information

Child's First Name

Child's Last Name

Birthday

Month

Day

Year

If my child shall require emergency treatment or care while under the supervision of Precious Lambs Preschool, I authorize the following plan of notification:

Mother's Name

First Name

Last Name

Mother's Address

Street

City

State

ZIP Code

Mother's Primary Phone

Mother's Secondary Phone

Mother's Work Address

Street

City

State

ZIP Code

Father's Name

First Name

Last Name

Father's Home Address (if different from above)

Street

City

State

ZIP Code

Father's Primary Phone

Father's Secondary Phone

Father's Work Address

Street

City

State

ZIP Code

If we cannot be reached, contact the following Emergency Contacts who live in the immediate area and are less that a 20 minute drive to preschool. These people have my permission to pick up my child or accompany him/her to an emergency facility. Two people are required to be listed.

Emergency Contact 1

First Name

Last Name

Emergency Contact 1 Relationship

Emergency Contact 1 Address

City

State

ZIP Code

Emergency Contact 1 Primary Phone

Emergency Contact 1 Secondary Phone

Emergency Contact 2

First Name

Last Name

Emergency Contact 2 Relationship

Emergency Contact 2 Address

City

State

ZIP Code

Emergency Contact 2 Primary Phone

Emergency Contact 2 Secondary Phone

Child’s Physician or Certified Health Practitioner (if medically exempt)

First Name

Last Name

Practice Name

Practice Address

City

State

ZIP Code

Allergies or other Medical Information (i.e. medications taking currently):

Date

Parent First Name

Parent Second Name

Signature

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