ECKAN HEAD START EMERGENCY CONTACT/RELEASE FORM DOB: Child’s Name: Mother/Mother Figure’s Name: 1: Phone 2: Father/Father Figure’s Name Phone 1: 2: Emergency Contacts Name: Relationship to Child: Phone 1: Phone 2: Date:   Pick Up & Emergency Contact Emergency Contact Only Pick Up Only Name: Relationship to Child: 1: Phone 2: Date:   Pick Up & Emergency Contact Emergency Contact Only Pick Up Only Name: Relationship to Child: Phone 1: Phone 2: Date:   Pick Up & Emergency Contact Emergency Contact Only Pick Up Only Name: Relationship to Child: Phone 1: Phone 2: Date:   Pick Up & Emergency Contact Emergency Contact Only Pick Up Only Relationship to Child: Name: Phone 1: Phone 2: Date:   Pick Up & Emergency Contact Emergency Contact Only Pick Up Only Name: Relationship to Child: Phone 1: 2: Date:   Pick Up & Emergency Contact Emergency Contact Only Pick Up Only Name: Relationship to Child: 1: Phone 2: Date:   Pick Up & Emergency Contact Emergency Contact Only Pick Up Only I authorize Head Start staff to contact the names listed above in case of an emergency. I also give permission to release my child to the name listed above. Parent Signature Date: Update(s): Parent Initials Date: Parent Initials Date:
ECKAN HEAD START EMERGENCY CONTACT/RELEASE FORM Child’s Name: DOB: Mother/Mother Figure’s Name: 1: Phone 2: Father/Father Figure’s Name Phone 1: 2: Emergency Contacts Name: Relationship to Child: Phone 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: Phone 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: Phone 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: Phone 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: Phone 1: 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only I authorize Head Start staff to contact the names listed above in case of an emergency. I also give permission to release my child to the name listed above. Parent Signature Date: Update(s): Parent Initials Date: Parent Initials Date:
2016-Application-Packet.docx