Name of Child
Start Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of School (Routine Destination)
School pick up time (If needed)
Parent's Phone Number
Format: (000) 000-0000.
PREMIER KIDS ACADEMY EMERGENCY CONTACT NUMBERS
Parent/Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
This form must be updated annually
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