Emergency Contact/Authorized Pick Up/ Allergies - Form 3
Hanover Church Preschool
Child's Name
First Name
Last Name
Sex
Birthday
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother
First Name
Last Name
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Employer
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Father's Employer
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact - Person 1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Emergency Contact - Person 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Child's Medial Care Provider Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list all individuals who are authorized to pick up your child after school and their phone number(s)
Special Disabilites
Food/Other Allergies
Medical or Dietary Information
Medication, Special Conditions
Additional Information on Special Needs of Child
Health Insurance or Medical Assistance and Policy Number
Parent's Signature is required for each item below to indicate parental consent
Obtaining Emergency Medical Care
Clear
Administration of Minor First Aid
Clear
Administration of Medication
Clear
Transportation in the Event of Emergency
Clear
Signature of Parent of Guardian
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform