Emergency Contacts & Authorized Pick-Up

Please list at least two contacts ( other than parents/guardians) to be called in an emergency if you are unreachable. These individuals are also automatically authorized for pick-up.

Pediatrician Name

Pediatrician Number

Address

Allergies: Please list all known allergies ( food, medication, insects, environmental) and describe the required response.

Dietary Restrictions or Special Diets:

Current Medications: List any medications your child takes regularly ( prescription or over-the-counter).

Any other medical conditions, physical limitations, or health concerns?

Please Upload Vaccine documentation

Signature

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