Nursery School Emergency Procedure Form Information About the ChildChild's First Name *Child's Middle NameChild's Last Name *Child's Home Address *Apartment, suite, etcCity *State *ZIP Code *Child's Date of Birth *Height *Weight *Last tetanus immunization *Please indicate any allergies, medication, or concerns that emergency care providers need to be aware of.Parent(s)/Guardian(s) Emergency Contact InfoAdd additional parents/guardians by clicking 'Add Parent/Guardian' below.Parent/Guardian's First Name *Parent/Guardian's Middle NameParent/Guardian's Last Name *Relation *Parent/Guardian's Email Address *Phone # *Phone #Phone #Additional Emergency Contact InfoPerson(s) who may be contacted if neither parent/guardian can be reached.Parent/Guardian's First Name *Parent/Guardian's Middle NameParent/Guardian's Last Name *Relation *Email Address *Phone # *Phone #Phone #Medical ContactsDoctor *Doctor Phone # *Doctor Phone # *Dentist Phone # *Hospital Preference *Insurance Carrier *Policy/Group # *Consent *In the event that I cannot be reached immediately in an emergency, I hereby give permission to the Director or Head Teacher to authorize emergency medical care or my child to paramedics or another physician to secure proper treatment for all emergencies.Signature *Use your mouse, trackpad or finger to sign here.Your browser does not support e-Signature field.Submit
