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)

First Last

Primary Phone

Father's Name, Place of Employment

Father's Work Phone

Father's Cell Phone

Mother's Name, Place of Employment

Mother's Work Phone

Mother's Cell Phone

Emergency Contact (#1) Other Than Parents

First Last

Emergency Contact (#1) Phone

Authorized to Pickup?

Emergency Contact (#1) Other Than Parents

Emergency Contact (#2) Other Than Parents

First Last

Emergency Contact #2 Phone

Authorized to Pickup?

Emergency Contact (#2) Other Than Parents

Pediatrician

First Last

Pediatrician Phone Number

Preferred Hospital

Signature

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

Name

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