Staff Emergency Information

Staff Emergency Contact and Medical Information

We will keep this information for each staff member in hardcopy form in a binder for emergency use, as a backup to electronic records. This information is voluntarily provided to Cathedral Preschool and will be kept confidential, ONLY to be released in the event of a medical emergency.
Staff Name(Required)
MM slash DD slash YYYY
Name of Physician
Spouse's Name
Emergency Contact Other Than Spouse
Please list any allergies here
Please list all current medications here
MM slash DD slash YYYY
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.