Emergency Contact Information

Note: This form will be submitted electronically.

* Required Fields

Date:

* Name of Child: * Birth Date: (mm/dd/yyyy)

* Address:

* City:

* Contact Phone: (937) 000-0000)


* Allergies
Yes No

If Yes, List Allergies:

If Yes, you must fill out the Child Medical/Physical Care Plan, JFS 01236.
This form is required by the Ohio Department of Job and Family Services.
It is available in MS Word format and in PDF format.

It must be printed, completed, and signed by the parent, administrator, and trained staff before the child's first day of school. It is due prior to your child's first day of school..


Fill in all required fields. If field does not apply, type N/A.

* Name of Mother:

* Home Phone:  * Cell Phone: 

* Employer: * Work Phone:

* Mother Works:    Yes      No  


Mother Work Schedule If Applicable::
  Time In Time Out
 Tuesday
 Wednesday
 Thursday
 Friday

 
Fill in all required fields. If field does not apply, type N/A

* Name of Father: 

* Home Phone:  * Cell Phone:  

* Employer: * Work Phone: 

* Father Works:  Yes    No


* Father Work Schedule If Applicable::
  Time In Time Out
 Tuesday
 Wednesday
 Thursday
 Friday

 
Fill in all required fields. If field does not apply, type N/A

* Name of Guardian:

* Home Phone:  * Cell Phone:  

* Employer: * Work Phone: 

* Guardian Works:  Yes     No


* Guardian Work Schedule If Applicable:
  Time In Time Out
 Tuesday
 Wednesday
 Thursday
 Friday

 

In Case Of Emergency Contact/Authorized To Pick Up

The primary caregiver for the child cannot be listed as an emergency contact.

* List the names of at least three (3) people who can be reached in the event of an emergency or illness if you (the primary caregiver) cannot be reached.

Any person listed must::

  • be able to assist the Center in contacting you
  • be at least 1/2 hour from the Center
  • take responsibility for the child in case you cannot be contacted
All fields are required to be filled. If any field does not apply, type N/A.
 

Contact Person

Relationship

Phone(s)


1

Home:
Cell:
Work:

2

Home:
Cell:
Work:

3

Home:
Cell:
Work:

 
Human Validation

Please type the letters as you see them in the image above. The letters are case sensitive