Emergency Card

Mother's Day Out Emergency Card

Semester Registering for: *

Spring Summer Fall

* Indicates required field

Child's Name *

First

Last

Birthday *

Mother's (Guardian) Name *

First

Last

Prefered Email Address *

Father's (Guardian) Name *

First

Last

Mother's Phone *

Alternate Number *

Father's Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Person to Contact (other than parents) in case of emergency *

First

Last

2nd Emergency Contact *

First

Last

Phone Number *

Who (besides you) has permission to pick up your child? *(please include phone number) *

Is there any special information we should know about releasing your child? *

Please note any allergies, special problems or feeding instructions for your child: (If no, write none) *

In the event that I cannot be reached to make arrangements for emergency medical attention, I hereby authorize First United Methodist Church to call 911 and initiate procedures.

Doctor's Name *

First

Last

Address *

Parent Signature *

Phone Number *

Date *

I give permission for my child to participate in field trips with First United Methodist Church, and provide emergency medical care for my child if I cannot be reached.

Parent Signature *

Date *

I understand that with any childcare there are risks involved that relate to everyday activities. First United Methodist Church, the Mother's Day Out teachers and all employees will take every precaution necessary to prevent any injury from occurring however, in the event of an injury First United Methodist Church and the Mother's Day Out Program (its employees and its facility) are not held liable.

Parent Signature *

Date *

Submit