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Student Emergency Contact Information

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.

Child's Name(Required)
Father's Name
Mother's Name
Emergency Contact (#1) Other Than Parents(Required)
Emergency Contact (#1) Other Than Parents
Emergency Contact (#2) Other Than Parents(Required)
Emergency Contact (#2) Other Than Parents
Pediatrician(Required)
Please try to be legible: your signature is required for Kentucky child care licensure purposes.
This field is for validation purposes and should be left unchanged.