EMERGENCY INFORMATION NOTE: THIS ENTIRE FORM MUST BE UPDATED SEMI-ANNUALLY. Child's Name Birth Date Last First Enrollment Date Hours & Days of Expected Attendance Child's Home Address Street/Apt. # City State Zip Code Parent/Guardian 1: Parent/Guardian 2: Name: Name: Home Address: Home Address: Home Phone: Home Employer/School: Employer/School: Employer/School Address: Employer/School Address: Work Work Phone: Cell Phone: Cell Phone: Email: Personal Security Pin: Personal Security Pin: Name of Person Authorized to Pick-Up Child (daily) Last First Relationship to Child Address Street/Apt. # City State Zip Code Telephone When parents cannot be reached, list at least two people who may be contacted to pick up in an emergency: 1. Name Relationship Last First Telephone (H) (W) (Cell) Address Street/Apt. # City State Zip Code 2. Name Relationship Last First Telephone (H) (W) (Cell) Address Street/Apt. # City State Zip Code 3. Name Relationship Last First Telephone (H) (W) (Cell) Address Street/Apt. # City State Zip Code
EMERGENCY INFORMATION NOTE: THIS ENTIRE FORM MUST BE UPDATED SEMI-ANNUALLY. Child's Name Birth Date Last First Enrollment Date Hours & Days of Expected Attendance Child's Home Address Street/Apt. # City State Zip Code Parent/Guardian 1: Parent/Guardian 2: Name: Name: Home Address: Home Address: Home Phone: Home Employer/School: Employer/School: Employer/School Address: Employer/School Address: Work Work Phone: Cell Phone: Cell Phone: Email: Personal Security Pin: Personal Security Pin: Name of Person Authorized to Pick-Up Child (daily) Last First Relationship to Child Address Street/Apt. # City State Zip Code Telephone When parents cannot be reached, list at least two people who may be contacted to pick up in an emergency: 1. Name Relationship Last First Telephone (H) (W) (Cell) Address Street/Apt. # City State Zip Code 2. Name Relationship Last First Telephone (H) (W) (Cell) Address Street/Apt. # City State Zip Code 3. Name Relationship Last First Telephone (H) (W) (Cell) Address Street/Apt. # City State Zip Code
New-Enrollment-Packet-1.docx