I n c a s e o f a n e m e r g e n c y o r if y o u r c h i l d b e c o m e s i l l a n d w e c a n n o t r e a c h y o u ,
t h e following people have authorization t o pick u p y o u r child.
1) N a m e
^
Work Phone
Address
—
Relationship to Child
Home
2) N a m e .
Work Phone
Address
•
Relationship to Child .
P l e a s e list a n y allergies y o u r child has
Parent Signature
Phone.
H o m e Phone_
_
•
—