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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:____________