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:
/
Month
/
Day
Year
Date
Full name of individual:
*
Home address:
*
Street Address, City, Zip Code
Phone Number
*
-
Area Code
Phone Number
Email:
*
example@example.com
Emergency Contacts:
Primary Contact
Name:
*
Address:
*
Street Address, City & Zip Code
Phone Number #1:
*
-
Area Code
Phone Number
Phone Number #2:
-
Area Code
Phone Number
Secondary Contact
Name:
*
Address:
*
Street Address, City & Zip Code
Phone Number #1
*
-
Area Code
Phone Number
Phone Number #2
-
Area Code
Phone Number
Health Care Provider
Choice of health care professional:
*
Address:
*
Street Address, City & Zip Code
Phone Number
*
-
Area Code
Phone Number
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