Where I will be: ______________________________
I will be home by: _____________________________
Number(s) to contact me on:_____________________
___________________________________________
If I am not reachable call: ________________________
at: _________________________________________
In Case of an Emergency:
Police: _________________________________________
Fire dept.: ______________________________________
This address:____________________________________
______________________________________________
This phone number:________________________________
If you cannot reach me in an emergency the following contacts
can be trusted to help you.
Contact 1
Name: _______________________________________
Number: ______________________________________
Address: _____________________________________
Contact 2:
Name: ________________________________________
Number: ______________________________________
Address: ______________________________________
Insurance company: ______________________________
Policy number: __________________________________
About the Children:
Names: _______________________________________
______________________________________________
Ages: _________________________________________
Bed time(s): ____________________________________
______________________________________________
Allergies: ______________________________________
______________________________________________
Medication(s): __________________________________
_____________________________________________
Additional information: _____________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
* PERMISSION IS GRANTED: Any licensed physician,
dentist, or hospital may givenecessary emergency medical
service to my child at the request of the person bearing this
form with note to the allergies, medications and other information
listed above.
Signed (parent/guardian): _____________________Date: _________