Page 27 - Demo

Child’s information
Child’s First and last name: home address:
home Phone:
parent/guardian ContaCt information
NiCkname:
date oF Birth:
Cell Phone:
Cell Phone:
CHILD EMERGENCY INFORMATION CARD
Child EmErgEnCy information CARD Please fill out the following information.
Please fill out the following information.
First and last name: Work Phone:
E-mail:
First and last name: Work Phone:
E-mail:
home Phone:
home Phone:
emergenCY ContaCt information (child may bE rElEasEd To ThE pErsons bElow iF parEnT/guardian is unavailablE):
First and last name: address:
Cell Phone:
First and last name: address:
Cell Phone:
First and last name:
address: Cell Phone:
Work Phone:
Work Phone:
Work Phone:
relationshiP to Child: Home Phone: E-mail:
relationshiP to Child: Home Phone: E-mail:
relationshiP to Child: Home Phone: E-mail:
relationshiP to Child: Cell Phone:
Phone numBer:
Phone numBer:
Phone numBer:
Out-Of-State cOntact (in casE in-sTaTE calls cannoT bE madE): First and last name:
address: Work Phone:
CHILD'S MEDICAL CARE
home Phone:
PhysiCian’s name:
address:
E-mail: wEbsiTE: mediCal Conditions, sPeCial needs, allerGies, mediCations, etC.:
dentist’s name: address: E-mail: hosPital name: address:
wEbsiTE:
i Grant Permission For the Child Care ProGram to Provide or arranGe For mediCal treatment and/or transPortation to aN EVACUATION site and/or mediCal FaCility For my Child durinG an emerGenCy or disaster. i Grant Permission For my Child to Be released to any oF the emerGenCy ContaCts desiGnated aBove iF i am unaBle to PiCk them uP in an emerGenCy.
print Parent/Guardian name: SIGnature DAte: PRINT PARENT/GUARDIAN NAME: SIGnature DAte:
Save the Children Federation, Inc. (2014)
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