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Emergency Information
Childs Information

Childs Name:_______________________________________________________
Childs Birthday: _____________________
Days in Daycare: _____________________________________________________
Hours in Daycare: ____________________
Childs Health Card #: _______________________
Childs Home Address: ________________________________________________
Childs Home Phone #: (

) _________ - ______________

Childs Dr.s Name: __________________________________

Childs Dr.s Phone #: (

) _________ - ______________

Childs Dr.s Address: _________________________________________________

Mothers or Guardian #1 Information

Name: _____________________________________________________
Birthday: ____________________
Home Address: _____________________________________________________
Home Phone #: (
Cell Phone #: (

) _________ - ______________
) _________ - ______________

Work or School: ____________________________________________________

Work Address: _______________________________________________________
Work Phone #: (

) _________ - ______________

Emergency Information
Fathers or Guardian #2 Information

Name: _____________________________________________________
Birthday: ____________________
Home Address: _____________________________________________________
Home Phone #: (
Cell Phone #: (

) _________ - ______________
) _________ - ______________

Work or School: ____________________________________________________

Work Address: _______________________________________________________
Work Phone #: (

) _________ - ______________

Name of Person(s) Authorized to pick up child

Name: ____________________________________________________________
Relationship to Child: _______________________________
Home Phone #: (

) _________ - ______________

Work Phone #: (

) _________ - ______________

Name: ____________________________________________________________
Relationship to Child: _______________________________
Home Phone #: (

) _________ - ______________

Work Phone #: (

) _________ - ______________

Name: ____________________________________________________________
Relationship to Child: _______________________________

Home Phone #: (

) _________ - ______________

Work Phone #: (

) _________ - ______________

Emergency Information
Names of people who will be contacted in an emergency

Name: ____________________________________________________________
Relationship to Child: _______________________________
Home Phone #: (

) _________ - ______________

Work Phone #: (

) _________ - ______________

Name: ____________________________________________________________
Relationship to Child: _______________________________
Home Phone #: (

) _________ - ______________

Work Phone #: (

) _________ - ______________

Name: ____________________________________________________________
Relationship to Child: _______________________________
Home Phone #: (

) _________ - ______________

Work Phone #: (

) _________ - ______________

Parents Signature: _______________________________________ Date: _____________________

Parents Signature: _______________________________________ Date: _____________________