Emergency Contacts
Ready Steps Mother's Day Out
Student's Name
*
Last, First, Middle
Student's Birthday
*
-
Month
-
Day
Year
Month, Day, Year
Age (at this time):
Student's Gender
*
Male
Female
Mother/Guardian's Name
*
Mother/Guardian's Contact Number
*
Mother/Guardian's Alternate Number
*
Father/Guardian's Name
*
Father/Guardian's Contact Number
*
Father/Guardian's Alternate Number
*
Preferred Email Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name (other than parent/guardian in an emergency)
*
Emergency Contact Number
*
Additional Emergency Contact (other than parent/guardian)
Alternate Contact Number
Who (besides you) has permission to pick up your child?
(Name & relation to child)
Alternate Pick Up's Contact Number
Special information we should know about releasing your child:
*
Please note any allergies, special problems or feeding instructions:
*
If no, write "None"
Doctor's Name:
*
Parent/Guardian's signature
*
Parent/Guardian's signature
Date
-
Month
-
Day
Year
Date
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