2022 SUMMER CAMP EMERGENCY CARD

2022 SUMMER CAMP EMERGENCY CARD
Camper Information
Camper's Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Grade in Fall 2022 *

Preschool KinderPrep Kindergarten
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Parent 1 Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Parent 2 Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
The Following People Have Permission to Pick Up My Child: (Photo ID Will Be Required)
Name *

First Name Last Name
Relationship *
Work Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Name

First Name Last Name
Relationship
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Name

First Name Last Name
Relationship
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Kaleidoscope Preschool Emergency Policy
In the event of serious illness or injury occurring within the jurisdiction of Kaleidoscope Preschool, the school will first attempt
to reach you and/or your physician. If she/he is unavailable, a school official will make arrangements with a physician, hospital or
emergency room for immediate care. I give permission to KALEIDOSCOPE PRESCHOOL to act in my behalf to make
whatever emergency measures (such as first aid, disaster and evacuation) as are judged necessary for the care and protection
of my child while under the supervision of the school.
IN THE EVENT OF EMERGENCY/INJURY WHEN PARENT/GUARDIAN IS NOT AVAILABLE, PLEASE NOTIFY:
Name *

First Name Last Name
Relationship *
Work Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Name *

First Name Last Name
Relationship *
Work Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Physician's Name *

First Name Last Name
Physician's Phone Number *

Area Code Phone Number
ALLERGIES of Camper *
Medications Camper takes
Attach camper's immunization record

Browse Files

Cancel of
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: