Emergency Contact Information FormEmergency Contact InformationChild's Name*NicknameDate of Birth* MM slash DD slash YYYY Home Telephone NumberHome Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's NameFather's Business Telephone NumberMother's NameMother's Business Telephone NumberPreferred Email Address Persons to contact in case of an emergency when parents cannot be reachedEmergency Contact Name 1Telephone NumberEmergency Contact Name 2Telephone NumberPerson(s) authorized to pick child up (other than mother & father)NameRelationshipPhoneNameRelationshipPhoneNameRelationshipPhoneSpecial Needs of Child and/or Physical LimitationsSiblings Names & AgesSiblings Names & AgesSiblings Names & AgesSiblings Names & AgesChildhood Diseases/IllnessesFearsToilet Habits (Special words, problems, etc)Special likes/dislikesComments helpful to the needs of your childParent/Guardian Name*CommentsThis field is for validation purposes and should be left unchanged.Δ