Child Emergency Form
Name of Child
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child Info
Teacher’s Name
Grade Level
School Info
Dismissal Time
Early Dismissal Time
Pick-up & Drop-off Info
Pick-up Location
Name
Street Address
City
State / Province
Postal / Zip Code
Drop Off Location
Name
Street Address
City
State / Province
Postal / Zip Code
School Name
Street Address
Address Line 2
City
State
Zip
Name of Parent/Guardian
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the parent working?
Yes
No
Work Place
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family and Emergency Contacts
Other people related to the child (other family members and emergency contacts)
*
Names of persons other than parent to whom child may be released
*
Health Information
If the child has any health conditions and/or allergies please explain
Do you want to add some medical documents?
Browse Files
Drag and drop files here
Choose a file
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of
Name of Physician/Pediatrician
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Medical Facility
Insurance Company
Policy Number
Consent & Acknowleddgment
Consent & Acknowledgment I, the undersigned parent/guardian, authorize Trip R Transportation to seek emergency medical treatment for my child if I cannot be reached. I release Trip R Transportation, its staff, and affiliates from liability in case of accident or emergency, provided reasonable care is taken.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: