2021 SUMMER CAMP PADDINGTON STATION PRESCHOOL EMERGENCY CARD

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* 1. STUDENT INFORMATION

Student's First and Last Name

Home Address

City

Zip Code

Date of Birth

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* 2. If student splits time between two households, please provide additional address (optional):

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* 3. CHILD'S HEALTH INFORMATION (forms to provide more details will be provided to you by the School if required)

List Known Allergies/Reactions

List Chronic Illnesses/Special Needs

List Medications

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* 4. PARENT/LEGAL GUARDIAN 1

First and Last Name

Mobile Phone Number

E-Mail Address

Job Title and Employer

Work Address

Work Phone Number

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* 5. PARENT/LEGAL GUARDIAN 2

First and Last Name

Mobile Phone Number

E-Mail Address

Job Title and Employer

Work Address

Work Phone Number

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* 6. EMERGENCY CONTACT 1

First and Last Name

Relationship to Student

Mobile Phone Number

Work/Alternate Phone Number

E-mail Address

Home Address

May Pick-up Student from School (YES/NO)

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* 7. EMERGENCY CONTACT 2

First and Last Name

Relationship to Student

Mobile Phone Number

Work/Alternate Phone Number

E-mail Address

Home Address

May Pick-up Student from School (YES/NO)

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* 8. ADDITIONAL "OK TO PICK-UP" AUTHORIZATION 1 (optional)

First and Last Name

Relationship to Student

Mobile Phone Number

Work/Alternate Phone Number

Home Address

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* 9. ADDITIONAL "OK TO PICK-UP" AUTHORIZATION 2 (optional)

First and Last Name

Relationship to Student

Mobile Phone Number

Work/Alternate Phone Number

Home Address

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* 10. CHILD'S DOCTOR

Name of Doctor/Practice

Phone Number

Address

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* 11. CHILD'S DENTIST

Name of Dentist/Practice

Phone Number

Address

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* 12. PREFERRED HOSPITAL

Name of Hospital

Hospital Phone Number

Hospital Address

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* 13. CHILD'S MEDICAL INSURANCE INFORMATION

Insurance Company

Policy Holder

Group Number

Policy Number

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* 14. I NEED RESOURCES TO OBTAIN MEDICAL INSURANCE

Yes

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* 15. CHILD'S HEARING, VISION AND DENTAL SCREENING INFORMATION

Please check the appropriate box or boxes below.

My child has had a hearing screening.

I need resources for a hearing screening.

My child has had a vision screening.

I need resources for a vision screening.

My child has had a dental screening.

I need resources for a dental screening.

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* 16. We authorize the School and its personnel to arrange for the transportation, by emergency vehicle if necessary, to a hospital or other medical facility, in case of an injury or illness to the Student, in the event a family member cannot be reached in a timely manner under the circumstances. Any doctor, transfer service, or medical facility may rely on this release.

Parent/Legal Guardian 1 Electronic Signature (type full name)

Parent/Legal Guardian 2 Electronic Signature (type full name)

Today's Date

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* 1. STUDENT INFORMATION

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* 2. If student splits time between two households, please provide additional address (optional):

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* 3. CHILD'S HEALTH INFORMATION (forms to provide more details will be provided to you by the School if required)

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* 4. PARENT/LEGAL GUARDIAN 1

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* 5. PARENT/LEGAL GUARDIAN 2

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* 6. EMERGENCY CONTACT 1

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* 7. EMERGENCY CONTACT 2

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* 8. ADDITIONAL "OK TO PICK-UP" AUTHORIZATION 1 (optional)

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* 9. ADDITIONAL "OK TO PICK-UP" AUTHORIZATION 2 (optional)

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* 10. CHILD'S DOCTOR

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* 11. CHILD'S DENTIST

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* 12. PREFERRED HOSPITAL

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* 13. CHILD'S MEDICAL INSURANCE INFORMATION

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* 14. I NEED RESOURCES TO OBTAIN MEDICAL INSURANCE

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* 15. CHILD'S HEARING, VISION AND DENTAL SCREENING INFORMATIONPlease check the appropriate box or boxes below.

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* 15. CHILD'S HEARING, VISION AND DENTAL SCREENING INFORMATION

Please check the appropriate box or boxes below.