Student Emergency Contact Information

2026-27 Student Emergency Contact Info

Emergency Contact and Medical Information, Authorization of Emergency Medical Care – The information from this online form will be combined with other essential information already provided by you via Brightwheel/Registration forms. We will keep this information for each student in hardcopy form in a binder for emergency use, as a backup to electronic records.

This field is for validation purposes and should be left unchanged.

Child's Name(Required)

First Last

Primary Phone(Required)

Father's Name

First Last

Father's Place of Employment / Job Title

Father's Work Phone

Father's Cell Phone

Mother's Name

First Last

Mother's Place of Employment / Job Title

Mother's Work Phone

Mother's Cell Phone

Emergency Contact (#1) Other Than Parents(Required)

First Last

Emergency Contact (#1) Email – Must be a unique email address (no duplicates)(Required)

Emergency Contact (#1) Phone(Required)

Authorized to Pickup?(Required)

Emergency Contact (#1) Other Than Parents

Emergency Contact (#2) Other Than Parents(Required)

First Last

Emergency Contact (#2) Email – Must be a unique email address (no duplicates)(Required)

Emergency Contact #2 Phone(Required)

Authorized to Pickup?(Required)

Emergency Contact (#2) Other Than Parents

Pediatrician(Required)

First Last

Pediatrician Phone Number(Required)

Preferred Hospital(Required)

Other Preferred Hospital(Required)

Please provide hospital name and phone number.

Name of Person Filling Out This Form

First Last

Signature

Please try to be legible: your signature is required for Kentucky child care licensure purposes.