Child’s Name_________________________________________________Birthdate_________________
Parent’s Names________________________________________________________________________
Home Phone#_____________________________Cell Phone#__________________________________
Mother’s Employer_________________________________________Phone #_____________________
Father’s Employer__________________________________________Phone #_____________________
Describe the best way to reach parent or guardian while child is at Kids N Motion. If staff is unable to reach the parents, they will
attempt to reach a neighbor, relative or friend who will assume responsibility for care of the child in an emergency.
Name #1__________________________________________________Phone #______________________
Address_______________________________________________Relationship______________________
Name #2__________________________________________________Phone #______________________
Address_______________________________________________Relationship______________________
Names of persons (other than parents) AUTHORIZED to take the child from school. Include any carpool
arrangements:
Name______________________________________________________Phone#____________________
Name______________________________________________________Phone#____________________
Names of persons specifically UNAUTHORIZED to take the child from school:
Physician___________________________________________________Phone#_____________________
Dentist_____________________________________________________Phone#_____________________
List any known allergies_______________________________Date of last DPT/tetanus________________
Other significant medical information________________________________________________________
Medical Insurance
carrier:______________________________________ID#_________________Group#________________
I understand that in some emergency situations the staff will need to contact the Emergency Medical
Service (911) before the parent, child’s physician, or other adult acting on the child’s behalf. In the event
of a non-life-threatening medical emergency, my child should be transported ____________________
hospital. If it is a life-threatening emergency, I understand that the child will be transported at the
expense of me or my insurance carrier. If no hospital is designated, we will transport to Potomac
Hospital. I hereby grant permission to the staff of Kids N Motion to take whatever emergency
measures are judged necessary for the care and protection of my child while under the care and
supervision of the preschool
Parent/Guardian signature___________________________________________Date__________________
Parent’s Names________________________________________________________________________
Home Phone#_____________________________Cell Phone#__________________________________
Mother’s Employer_________________________________________Phone #_____________________
Father’s Employer__________________________________________Phone #_____________________
Describe the best way to reach parent or guardian while child is at Kids N Motion. If staff is unable to reach the parents, they will
attempt to reach a neighbor, relative or friend who will assume responsibility for care of the child in an emergency.
Name #1__________________________________________________Phone #______________________
Address_______________________________________________Relationship______________________
Name #2__________________________________________________Phone #______________________
Address_______________________________________________Relationship______________________
Names of persons (other than parents) AUTHORIZED to take the child from school. Include any carpool
arrangements:
Name______________________________________________________Phone#____________________
Name______________________________________________________Phone#____________________
Names of persons specifically UNAUTHORIZED to take the child from school:
Physician___________________________________________________Phone#_____________________
Dentist_____________________________________________________Phone#_____________________
List any known allergies_______________________________Date of last DPT/tetanus________________
Other significant medical information________________________________________________________
Medical Insurance
carrier:______________________________________ID#_________________Group#________________
I understand that in some emergency situations the staff will need to contact the Emergency Medical
Service (911) before the parent, child’s physician, or other adult acting on the child’s behalf. In the event
of a non-life-threatening medical emergency, my child should be transported ____________________
hospital. If it is a life-threatening emergency, I understand that the child will be transported at the
expense of me or my insurance carrier. If no hospital is designated, we will transport to Potomac
Hospital. I hereby grant permission to the staff of Kids N Motion to take whatever emergency
measures are judged necessary for the care and protection of my child while under the care and
supervision of the preschool
Parent/Guardian signature___________________________________________Date__________________
| Emergency Information Form |
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