Child Emergency Contact Form

Securely collects a child's contact, health, and emergency contact details for schools or child care providers.

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Name

Nombre

Apellido

Birth Date

Blood Type

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Name

Nombre

Apellido

Phone Number (Cell)

Phone Number (Work)

Relationship Status

Parent Guardian Grandparent Sibling Other

Work Status

Employed Unemployed Self-employed Retired

Name

Nombre

Apellido

Phone Number (Cell)

Special Conditions

The child has Health Insurance:

Yes No

Other Notes

As the child's parent/guardian, by signing this field I agree to be responsible for all the charges which are excluded from health insurance in an emergency situation. If my child has no health insurance, I also agree to be responsible of all the charges about my child's health.

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