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Star Care Emergency Contact Form 2024-25
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 1
Name - 1
*
First Name
Last Name
Cell Phone - 1
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone - 1
Please enter a valid phone number.
Format: (000) 000-0000.
Place of Employment - 1
*
Primary Email
*
example@example.com
Parent/Guardian 2
Name - 2
First Name
Last Name
Cell Phone - 2
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone -2
Please enter a valid phone number.
Format: (000) 000-0000.
Place of Employment - 2
Primary Email
example@example.com
Physician's Name
*
First Name
Last Name
Physician's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinic Name
*
Clinic Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please mark all that apply
Allergies
Asthma
Diabetes
Seizures
Other
Health Concerns:
*
Please list any allergies or medications
Emergency Contacts
Please list people who are authorized to pick up your child if you can't be reached.
Emergency Contact - 1
*
First Name
Last Name
Address Emergency Contact - 1
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number Emergency Contact - 1
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Child - Emergency Contact - 1
*
Emergency Contact - 2
*
First Name
Last Name
Address Emergency Contact - 2
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number Emergency Contact - 2
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Child - Emergency Contact - 2
*
Emergency Contact - 3
First Name
Last Name
Address Emergency Contact - 3
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number Emergency Contact - 3
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Child - Emergency Contact - 3
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