INFORMATION AND EMERGENCY CARD

Date of Enrollment _______________

Name ________________________________ Date of Birth _____________________

Address ______________________________________________________________

Mother’s Name ___________________ Occupation ______________________

Address (if different) ___________________ Employer’s Name _________________

___________________ Address _________________________

Home Phone ___________________ Work Phone ______________________

Cell Phone ___________________

Father’s Name ___________________ Occupation ______________________

Address (if different) ___________________ Employer’s Name _________________

___________________ Address ________________________

Home Phone ___________________ Work Phone _____________________

Cell Phone ___________________

PLEASE LIST OTHER CHILDREN IN FAMILY:

Name Date of Birth Sex

___________________________ __________ ___

_________________ ___________ ___________________ __________

Physician of Choice Phone # Hospital of Choice Phone #

_________________ ___________

Family Dentist Phone #

Any known allergies? _______________________________________________

Last Tetanus Booster? ______________________________________________

Any Pertinent Medical Information ______________________________________

EMERGENCY PHONE NUMBERS (Friend or Relative):

This should be a person we can contact in case of illness or emergency if we are unable

to reach either parent and has the authorization to pick the child up.

Name ____________________ Phone # ___________ Relationship ____________

Signature _______________________________Date: _________________

I give permission to the Southport Congregational Preschool to take whatever

emergency (e.g. first aid, disaster evacuation) measures as judged necessary for the

care and protection of my child while under the supervision of the program.

In case of a medical emergency, I understand that my child will be transported to an

appropriate medical facility by the local emergency unit for treatment if the local

emergency resource (Police, Rescue Squad) deems it necessary. I, as the

parent/guardian, will assume all financial responsibility.

It is understood that in some medical situations, the staff will need to contact the local

emergency resource before the parent, child’s physician, and/or other adult acting on the

parent’s behalf. The Southport Congregational Preschool or the Southport

Congregational Church will not be held responsible in any situation.

I have read and discussed the Preschool’s Policy of Disciplinary Measures in the

2020-2021 Policies and Procedures Handbook. I understand the Policy and have no

questions.

SIGNATURE _______________________

(Parent or Guardian)

DATE: _______________________