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ANGELS UNLIMITED PRESCHOOL
615 W 5th ST
RED WING MN 55066
651 385 8133

EMERGENCY INFORMATION FORM

Name of Student:________________  Date:_____________

Date of Birth:___________________
Address:_______________________   Home Phone:___________

Parent's Names:
Father:_________________            Mother:___________________
Cell Phone:______________           Cell Phone:_______________
Work Phone:_____________           Work Phone:______________

NAME OF OTHER ADULTS WHO WILL TAKE RESPONSIBILITY FOR YOUR
CHILD IF YOU CANNOT BE REACHED:
1._____________________        2._________________________
Address:________________        ___________________________
Tel. No._________________        ___________________________

CHILD'S PHYSICIAN:______________ ADDRESS:______________
Tel. No.________________

CHILD'S DENTIST:______________ ADDRESS:_______________
Tel. No._______________________

Persons to contact if parents cannot be reached in an emergency:
1.________________ Address:_____________Telephone:_______
2.________________ Address:_____________Telephone:_______
STAFF WILL CALL UNTIL SOMEONE IS REACHED.

ADULTS WHO HAVE PERMISSION TO PICK UP YOUR CHILD AT SCHOOL:
1. ______________________        Telephone:________________
2._______________________        Telephone:________________

I GIVE PERMISSION FOR THE STAFF OF Angels Unlimited Preschool to
Administer SYRUP OF IPECAC if the need arises and advised by the POISON
CONTROL CENTER.
Parent's Signature:__________________ Date:____________

I GIVE THE STAFF OF Angels Unlimited Preschool PERMISSION TO ACT IN
MY CHILD'S BEHALF IN AN EMERGENCY OR WHEN A PARENT/ GUARDIAN
CANNOT BE REACHED.
Parent Signature:___________________   Date:____________

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