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)
Emergency Contact (#1) Other Than Parents
Emergency Contact (#1) Other Than Parents
Emergency Contact (#2) Other Than Parents
Emergency Contact (#2) Other Than Parents
Pediatrician
Consent for preschool staff to obtain emergency medical care.
Acknowledgement of steps to be taken for emergency medical care.
Acknowledgement of Family's Financial Obligation
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.