Emergency Information Form

Student's Name

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Mom's Name

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Dad's Name

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Home Phone

Mom Cell

Dad Cell

Mom/Dad Work Phone

Email(s)

Non-Parental Contacts (Name, Relationship – Phone)

In case of emergency and you cannot be reached, please list AT LEAST TWO individuals whom we can contact instead. By listing these individuals, you are also consenting to them picking up your child.

Please list any allergies and/or chronic illnesses/conditions we should know about your child:

Child's Doctor

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Doctor Phone

Hospital Preference

Any other pertinent information that may be useful in case of emergency:

EMERGENCY TREATMENT: I give unlimited authority to the staff members of Sunrise UMC Preschool to act in my behalf and to give, seek, and authorize all necessary emergency medical care for my child. If medical attention is needed and neither parent nor legal guardian can be reached by phone, I give permission for my child to be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to update this information whenever a change occurs.

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LIABILITY: I release and hold harmless Sunrise UMC, Sunrise UMC Preschool and its staff from liability for the consequences of safe medical treatment or decisions for the child listed above. Furthermore, I release and hold harmless Sunrise UMC, Sunrise UMC Preschool and its staff from liability for accidents occurring to me or my child. *

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