Emergency Information Form - Kent County Arc - Trudeau Center

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EMERGENCY INFORMATION

Participants Name: ________________________________________

Home Phone: ________________________________________

Primary Contact (please note times)	Secondary Contact (please note times)
________________________________________	________________________________________
________________________________________	________________________________________
In the event of an emergency, please contact: (other than parent)
________________________________________ Name	________________________________________ Name
________________________________________ Address	________________________________________ Address
________________________________________ City/State	________________________________________ City/State
________________________________________ Phone	________________________________________ Phone

To insure everyone’s safety we ask that you give us a list of people who have your permission to pick up your son/daughter. We will not release anyone with out consent of the parent in advance. A phone call or note will be required if your child will be getting picked up from anyone not listed.

________________________________________
Name

________________________________________
Relationship

________________________________________
Name

________________________________________
Relationship

________________________________________
Name

________________________________________
Relationship

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