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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 for "Child's Last Name"

Child's First Name*

Answer required for "Child's First Name"

Date of Birth*

Answer required for "Date of Birth"

Physical Address

Street Address*

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Parent/Guardian #1 Contact Information

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Email Address

Answer required for "Email Address"

Primary Phone

Number Required

Parent/Guardian #1 Employer

Place of Employment

Answer required for "Place of Employment"

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Work Phone

Answer required for "Work Phone"

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

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

Parent/Guardian #2 Contact Information

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Answer required for "Email"

Primary Phone

Number Required

Parent/Guardian #2 Employer

Place of Employment

Answer required for "Place of Employment"

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Work Phone

Answer required for "Work Phone"

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

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

Emergency Contact #1 (18+ years old)

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Answer required for "Email"

Primary Phone

Number Required

Work Phone

Number Required

Emergency Contact #2 (18+ years old)

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Answer required for "Email "

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 for "First Name"

Last Name

Answer required for "Last Name"

Answer required for "Email"

Primary Phone

Number Required

Work Phone

Number Required

Child's Preferred Sources of Medical Care

Hospital of Preference

Answer required for "Hospital of Preference"

Address

Answer required for "Address"

Phone

Number Required

Child's Doctor

Answer required for "Child's Doctor"

Doctor Address

Answer required for "Doctor Address"

Doctor Phone

Answer required for "Doctor Phone"

Child's Dentist

Answer required for "Child's Dentist"

Dentist Address

Answer required for "Dentist Address"

Dentist Phone

Answer required for "Dentist Phone"

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 for "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. "

Today's Date

Answer required for "Today's Date"