Saint Christine School
Extended Care Program

EMERGENCY ADDRESS FORM
       & SIGNATURE CARD
 
CHILD'S 
LAST NAME:
FIRST
NAME: 
DATE OF BIRTH: 
PHONE: 
HOME ADDRESS: 


ILLNESS OR ACCIDENT OR LEAVING CENTER PREMISES:

In the event of apparently serious illness or accident, when I cannot be reached I wish one of the following to be notified by telephone. They are authorized to act in my absence, and they have SIGNED their names on this card. They may also release my child from the center.
NAME:
PHONE: 
ADDRESS:
      
PARENT/GUARDIAN SIGNATURE:____________________________________________________________________
NAME:
PHONE: 
ADDRESS:
             
PARENT/GUARDIAN SIGNATURE: ____________________________________________________________________

THE FOLLOWING PERSON(S) MAY NOT CALL FOR MY CHILD:

NAME:
NAME:


PHYSICIAN INFORMATION:
DOCTOR
NAME:
PHONE:

If one of the above cannot be reached, I wish my child to be taken to the EMERGENCY HOSPITAL

 YES NO


 

 

  I wish any one of the following doctors to be notified:

DOCTOR
NAME:
PHONE:
DOCTOR
NAME:
PHONE:

SPECIAL INSTRUCTIONS:

Special Instructions-Allergies?

Any Chronic Illness?


PARENTAL BUSINESS  INFORMATION:  

The following telephone numbers may be used in cases of emergency.
MOTHER'S 
LAST NAME:
FIRST
NAME: 
BUSINESS ADDRESS: 
BUSINESS
PHONE: 
FATHER'S 
LAST NAME:
FIRST
NAME: 
BUSINESS ADDRESS: 
BUSINESS
PHONE: 

I HAVE READ ALL THE INFORMATION IN THE PARENTS INFORMATION PACKET AND I AGREE TO ABIDE BY 
THESE TERMS FOR AS LONG AS MY CHILD(REN) ARE ENROLLED IN THE PROGRAM: 


TO PRINT THIS FORM, CLICK ON THE BROWSER'S PRINT BUTTON.
 BE SURE TO SIGN & RETURN THE FORM TO THE EXTENDED CARE DIRECTOR.
PARENT/GUARDIAN SIGNATURE:________________________________________    DATE:  ____________

© 2003 St. Christine Parish

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