Family Emergency Contact Information

Contact information for parent/guardian and authorization for emergency contact in the case that parents cannot be reached.

Child's Full Name

Parent/Guardian One *

Full Name

Cell Phone

Home Phone

Home Address

Place of Employment

Work Phone (ext.)

Parent/Guardian Two

Full Name

Cell Phone

Home Phone

Home Address

Place of Employment

Work Phone (ext.)

EMERGENCY CONTACTS (in the event that both parents/guardians cannot be reached)

Contact One *

Full Name

Cell Phone

Home Phone

Home Address

Place of Employment

Work Phone (ext.)

Contact Two

Full Name

Cell Phone

Home Phone

Home Address

Place of Employment

Work Phone (ext.)

Authorize

I herby authorize the directors of Emerson Academy to contact the above persons in the event of an emergency or a situation where my child requires medical attention.

The above persons are authorized to pick my child/ren up from Emerson Academy in the event that neither parent/guardian can be reached.

Signature of Parent(s)/Guardian(s)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Family Emergency Contact Information

Links

Programs

Contact