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Emergency Contacts and Authorized Pick Up

Please complete the AXIS International Preschool Emergency Contact and Authorized Pick Up Form. Required fields marked with an asterisk *

Child's Last Name*

Answer Required

Child's First Name*

Answer Required

Date of Birth*

Answer Required

Physical Address

Street Address*

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Parent/Guardian #1 Contact Information

First Name

Answer Required

Last Name

Answer Required

Email Address

Answer Required

Primary Phone

Number Required

Parent/Guardian #1 Employer

Place of Employment

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Work Phone

Answer Required

Please list any special instructions for contacting parent/guardian 1 when this child is at our center.

Answer Required

Parent/Guardian #2 Contact Information

First Name

Answer Required

Last Name

Answer Required

Primary Phone

Number Required

Parent/Guardian #2 Employer

Place of Employment

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Work Phone

Answer Required

Please list any special instructions for contacting parent/guardian #2 when this child is at our center.

Answer Required

Emergency Contact #1 (18+ years old)

First Name

Answer Required

Last Name

Answer Required

Primary Phone

Number Required

Work Phone

Number Required

Emergency Contact #2 (18+ years old)

First Name

Answer Required

Last Name

Answer Required

Mobile Phone

Number Required

Work Phone

Number Required

Additional Individual Authorized to Pick Up Your Child (Should be local and 18+ years old)

First Name

Answer Required

Last Name

Answer Required

Primary Phone

Number Required

Work Phone

Number Required

Child's Preferred Sources of Medical Care

Hospital of Preference

Answer Required

Address

Answer Required

Phone

Number Required

Child's Doctor

Answer Required

Doctor Address

Answer Required

Doctor Phone

Answer Required

Child's Dentist

Answer Required

Dentist Address

Answer Required

Dentist Phone

Answer Required

Authorization for emergency medical care and transportation: In the event of an emergency I hereby give my permission for child care staff to access emergency medical services for my child, including transport to the nearest healthcare facility, to receive emergency medical or surgical care and treatment. It is understood that a conscientious effort will be made to locate me, and I accept the expense of care and transport Please type your full name below as your signature.

Answer Required

Today's Date

Answer Required