Emergency Contact

2018-2019 Emergency Contact

* Indicates required field

Child's Name *

First

Last

Session *

Parent/Guardian 1 Name *

First

Last

P/G 1 Phone Number *

Parent/Guardian 2 Name *

First

Last

P/G 2 Phone Number *

Caregiver Name *

First

Last

Caregiver Phone Number *

Please list up to 4 others who may pick-up your child (name, relationship, AND phone numbers) *

In the event of an emergency, we will first attempt to contact parents/guardians listed above. Please provide additional emergency contacts if parents/guardians cannot be reached.

Emergency Contact 1 Name *

First

Last

EC 1 Phone Number *

Emergency Contact 2 Name *

First

Last

EC 2 Phone Number *

Child's Physician *

First

Last

Physician's Phone Number *

Physician's Address *

Line 1

Line 2

City

State

Zip Code

Country

Hospital Preference *

I hereby give my permission for Kiddie Kampus staff members to obtain the services of the doctor listed above (or another if your child's physician cannot be reached), area EMT unit, or hospital in case the named student suffers illness or accident.

Emergency Contact Agreement *

Your Name *

First

Last

Submit

2018-2019 Emergency Contact

Kiddie kampus of PierceChurch.org