Additional Emergency Contact and Release

Additional Emergency Contact and Release
Child’s Name (Last, First, Middle Initial)*
Crèche Location*
Date of Birth*

MonthDayYear
Date
Please notify the school in advance if an Emergency Release Person will pick up your child. For safety, all authorized individuals must present a government-issued photo ID at pick-up and be at least 18 years old. At least one local contact must be listed and kept updated. Any changes to the Emergency Contact and Release list are subject to approval from both primary payers/guardians.
Contact #1*
Relationship to Child*
Home Phone*
Cell Phone*
Home Address*
Email Address*
example@example.com
Employer*
Title*
Employer’s Address*
Work Phone/Extension*
Work Hours*
Contact #2*
Relationship to Child*
Home Phone*
Cell Phone*
Home Address*
Email Address*
example@example.com
Employer*
Title*
Employer’s Address*
Work Phone/Extension*
Work Hours*
The persons designated in this section will be contacted and are authorized to pick up my child if there is a medical or other emergency and I cannot be reached. Parents/Guardians/Payers must complete any state-specific emergency release form required by individual state child care licensing regulations.
- The school will only release your child to you or individuals listed on their authorized pick-up list. In case of an emergency preventing you from picking up your child, please ensure trusted individuals are included on this list. If someone not listed needs to pick up your child, you must provide written authorization to the school in advance. If you are unable to submit written authorization and need to call instead, the school administration will verify your identity using your personal information before releasing your child.
- For all children’s safety, it is critical to use your secured access code to enter the building and check your child in and out according to state childcare licensing regulations. To ensure the safety of our school’s staff and children, please do not share your secured access code with anyone else.
- Please notify emergency contacts that they must bring government-issued identification when they pick up your child.
- If your child is picked up after closing time, you will be charged a late fee of $10.00 per every 5 minutes or a portion of 5 minutes, per child, until the child is picked up. Per state licensing regulations, we may be required to contact local authorities after a certain amount of time. Please contact your Director for additional information.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: