Emergency Information – Therapist/Volunteer

Emergency Information – Therapist/Volunteer

Child care providers, including the director, uncompensated providers, substitute providers, and volunteers must provide this information on or before the first day of work. Emergency information must be updated as changes occur and at least annually.
Date completed:

MonthDayYear
Date
Full name of individual:*
Home address:*
Street Address, City, Zip Code
Phone Number*

Area CodePhone Number
Email:*
example@example.com
Emergency Contacts:
Primary Contact
Name:*
Address:*
Street Address, City & Zip Code
Phone Number #1:*

Area CodePhone Number
Phone Number #2:

Area CodePhone Number
Secondary Contact
Name:*
Address:*
Street Address, City & Zip Code
Phone Number #1*

Area CodePhone Number
Phone Number #2

Area CodePhone Number
Health Care Provider
Choice of health care professional:*
Address:*
Street Address, City & Zip Code
Phone Number*

Area CodePhone Number
Should be Empty:

Emergency Contacts: