KMM Angel Care Program

This form ensures that the KMM Angel Care staff can provide proper care and respond promptly in the event of an emergency. This also helps establish communication between parents and the KMM Angel Care team regarding any special needs or preferences.
Child’s Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender

Emergency Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Way To Contact
Child's Physician Name

First NameLast Name
Child's Physician Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Hospital In Case of Emergency

Additional Information
Is there anything else we should know about your child?
Parent/Guardian Acknowledgment:
I confirm that the information provided is accurate to the best of my knowledge and authorize the daycare staff to care for my child.
Print Name
Date

MonthDayYear
Date
Should be Empty:

Child’s Information