EMERGENCY CONTACT FORM NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY. Child's Name * First Name Last Name Birth Date * MM DD YYYY Child's Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian Name * First Name Last Name Relationship * Phone Number * Name of Person Authorized to Pick up Child (daily) * First Name Last Name Any Changes/ Additional Information ANNUAL UPDATES When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency: 1. Name & Number * 2. Name & Number 3. Name & Number Child's Physician or Source of Health Care * Phone * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Does your child have an allergy? If yes, please state In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the Academy to have your-child transported to that hospital. Signature of Parent/Guardian Date MM DD YYYY Thank you!
