Emergency Contact Form

Emergency Contact Form 2024-2025

CHILD’S INFORMATION:

Child’s Full Name:

Date of Birth (DOB):

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Country

PRIMARY PARENT / GUARDIAN:

First Name

Last Name

Phone/Mobile

Physical Address (if different from child's):

Address Line 1

Address Line 2

City

State

Zip Code

Country

SECONDARY PARENT / GUARDIAN:

First Name

Last Name

Phone/Mobile

Physical Address (if different from child's):

Address Line 1

Address Line 2

City

State

Zip Code

Country

MEDICAL INFORMATION:

Allergies or intolerance to food or medicine and action to be taken in an emergency:

Child's Physician's Name:

Child's Physician's Contact:

Chronic Physical Problems/Pertinent Developmental Information:

Special Accommodations Required:

TWO EMERGENCY CONTACTS:

Name/Phone:

AUTHORIZED PERSONS:

Person(s) authorized to pick up child:

Person(s) NOT authorized to pick up child (include legal documentation if available):

AGREEMENTS:

Treble Makers Music will notify the parents whenever a child becomes ill and the parent will pick the child up as soon as possible. The child may return to class 24 hours after the last symptom of illness has ceased. The parent authorizes Treble Makers Music to obtain immediate medical care in case of emergency.

PARENT/GUARDIAN ACKNOWLEDGMENT: I have read and understood the stipulations mentioned above.

Signature

Sign Here

Date: