Family Emergency Contact Form

Required fields are indicated with a “*“.

Child admission ID: *

Parent or guardian one contact details:

Name:

E-mail:

Cell Phone Number:

Home Phone Number:

Home Address:

Place of Employment:

Work Phone Number with Extension:

Parent or guardian two contact details:

Name:

E-mail:

Cell Phone Number:

Home Phone Number:

Home Address:

Place of Employment:

Work Phone Number with Extension:

Who lives with your child?:

Please fillup Emergency Contacts (in the event that both parents/guardians cannot be reached)

Emergency person one contact details:

Name:

E-mail:

Cell Phone Number:

Home Phone Number:

Home Address:

Place of Employment:

Work Phone Number with Extension:

Emergency person two contact details:

Name:

E-mail:

Cell Phone Number:

Home Phone Number:

Home Address:

Place of Employment:

Work Phone Number with Extension:

I here by authorize the directors of Emerson Academy to contact the above persons in the event of an emergency or a situation where my child requires medical attention.

The above persons are authorized to pick my child/children up from Emerson Academy in the event that neither parent/guardian can be reached.

Parent or guardian one Name:

Parent or guardian two Name: