Emergency Information Card

Emergency contact and medical authorization form.

This field is for validation purposes and should be left unchanged.

School Name(Required)

Grade(Required)

Child's Name(Required)

First Last

Date of Birth(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian #1 Name(Required)

First Last

Parent/Guardian #1 Phone Number(Required)

Parent/Guardian #2 Name(Required)

First Last

Parent/Guardian #2 Phone Number(Required)

Emergency Contacts

In case you are unable to reach me during an emergency, you are authorized to contact and, if necessary, release my child to the following individuals.

Emergency Contact #1 Name(Required)

Emergency Contact #1 Phone Number(Required)

Emergency Contact #2 Name(Required)

Emergency Contact #2 Phone Number(Required)

Emergency Contact #3 Name(Required)

Emergency Contact #3 Phone Number(Required)

Out-of-State Emergency Contact

If the California telephone system is not functioning, we may contact the following out-of-state person.

Out-of-State Contact Name

Out-of-State Contact Phone Number

Allergies to Medication/Food

Family Doctor

Doctor Phone Number

Medical Authorization

As the legal custodian of the child listed above, I authorize Creative Kids Inc. personnel to consent to any X-rays, examinations, anesthesia, medical or surgical decisions, treatment, and/or hospital care upon the advice of any licensed physician and/or dentist.

Parent Signature(Required)

Signature Date(Required)

Emergency Information Card