Emergency Contact Form

Childs Name: __________________________________________ Birthdate: ___________________

Phone Number: __________________________________________
Address: ________________________________________________________________________________

Fathers (Guardians) Name: ______________________________________________________________

Home Phone: ________________________ _____ Work Number: ___________________________
Cell Number: _____________________________

Mothers (Guardians) Name: ______________________________________________________________

Home Phone: ________________________ _____ Work Number: ____________________________
Cell Number: _____________________________

E-mail Address: __________________________________________________________________________

Emergency Contacts:
1. Name:_________________________________ Phone Number: __________________________
Relationship to child: _______________________________________________________________
2. Name:_________________________________ Phone Number: __________________________
Relationship to child: _______________________________________________________________
3. Name:_________________________________ Phone Number: __________________________
Relationship to child: _______________________________________________________________

If you are not able to pick up your child, please list the names of people who are able to pick him or her
up (ID is required. If you do not list someone and send that person to pick up your child, he or she will
not be able to pick up your child):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
***Please be sure you contact your childs teachers as soon as something changes, as in your address,
phone number, emergency contacts, authorized people who can pick up your child, etc.***

_______________________________________________________ ________________________
Parent/Guardian Signature Date

New forms will be sent home every three months or whenever a change of address, phone number,
emergency contact, etc. are given to the teachers.