Atlanta Child Care | Atlanta Preschool

Emergency Contact Form

*All fields are required for us to better assist you.

Child's Name:
Date of Birth:
Address:

Father's Name:
Home Phone:
Work Phone:

Mother's Name:
Home Phone:
Work Phone:

Person to notify in an emergency and parents cannot be reached:

Name:
Phone:

Child's Doctor
Name:
Phone:
Affiliated Medical Facility:
Address:

Current prescribed medication:

Child's special needs and conditions:

Child's allergies:

In the event of an emergency involving my child, and if FIO360 cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.
Signatures needed upon visit to the facility.