​​Lil' Bloomers Daycare

​Love, Learning & Laughter

EMERGENCY INFORMATION

​

​Child’s Name________________________________________________________________

D.O.B. ______________________ Child’s Sex ____________ Child’s Nickname ______________________________

Child’s Physician _________________________________________ Phone __________________________________

Child’s known allergies, intolerance to food, or special health care needs: 

______________________________________________________________________________________________


Mother’s Name ____________________________________________________________________________________

Address: _________________________________________________________________________________________

Home Phone ___________________Work Phone ________________________Cell Number ____________________ 

Employer ________________________________ Employer Address _____________________________________

Email:_____________________________________________________________


Father’s Name ____________________________________________________________________________________

Address: _________________________________________________________________________________________

Home Phone _____________________Work Phone ______________________Cell Number_____________________ 

Employer _______________________________ Employer Address ________________________________________

Email:____________________________________________________________


In case of emergency when NEITHER parent can be reached, please contact:

(1)Name ______________________________________________Relationship to the child______________________

Address_______________________________________________________________________________________

Home Phone ____________________Work Phone ______________________Cell Number______________________


(2)Name _____________________________________________  Relationship to the child______________________

Address_______________________________________________________________________________________

Home Phone ____________________Work Phone ______________________Cell Number___________________ __


Persons authorized to pick up child: _________________________________________________________________
___________________________________________________

Persons unauthorized to pick up child: _______________________________________________
(Appropriate legal paperwork must be on file when custodial parent requests the center not to release the child to the other parent)

______________________________________                    ________________
Mother’s Signature                                                                             Date

______________________________________                    ___________________
Father’s Signature                                                                              Date