EMERGENCY CONTACT

Child's Name *
Child's Name
Date of Birth *
Date of Birth
Guardian 1 *
Guardian 1
Address *
Address
Mobile Phone *
Mobile Phone
Home or Work Phone
Home or Work Phone
Guardian 2
Guardian 2
Address (if different from above)
Address (if different from above)
Mobile Phone
Mobile Phone
Home or Work Phone
Home or Work Phone
Emergency Contact 1 *
Emergency Contact 1
Must live within 1/2 hour of the school
Contact Phone *
Contact Phone
Emergency Contact 2 *
Emergency Contact 2
Must live within 1/2 hour of the school
Contact Phone *
Contact Phone
Physician *
Physician
Physician Phone *
Physician Phone
This item may be served at the table with my child
I understand that in case of a medical emergency, my child may need to be transferred to the nearest hospital or outpatient facility. In an urgent situation, Primrose Hill School may need to contact local emergency services before contacting parents for guardians. If a child is ill or injured or in the event of an evacuation, the above individuals may be contacted and have permission to transport my child. *
By selecting the "I Accept" button, you are signing this Form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this Form. *