Emergency Information

Child's Name*
First Last
Child's Birthdate*
MM slash DD slash YYYY
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 Last
Mother's Home Address*
Street Address Address Line 2 City State ZIP Code
Mother's Primary Phone*
Mother's Secondary Phone
Mother's Work Address
Street Address Address Line 2 City State ZIP Code
Father's Name*
First Last
Father's Home Address (if different from above)
Street Address Address Line 2 City State ZIP Code
Father's Primary Phone*
Father's Secondary Phone
Father's Work Address
Street Address Address Line 2 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
Emergency Contact Name 1*
First Last
Emergency Contact 1 Relationship*
Emergency Contact 1 Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact 1 Primary Phone*
Emergency Contact 1 Secondary Phone
Emergency Contact 2
Emergency Contact Name 2*
First Last
Emergency Contact 2 Relationship*
Emergency Contact 2 Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact 2 Primary Phone*
Emergency Contact 2 Secondary Phone
Child’s Physician or Certified Health Practitioner (if medically exempt)
Medical Professional's Name*
First Last
Practice Name*
Practice Address*
Street Address Address Line 2 City State ZIP Code
Allergies or other Medical Information (i.e. medications taking currently):
Date*
MM slash DD slash YYYY
Parent Name*
First Last
Email*
Parent Signature*
Comments
This field is for validation purposes and should be left unchanged.

Emergency Information

Emergency Contact 1

Emergency Contact 2

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