Emergency Contact Form

Boulder Knoll Montessori School Emergency Form

Please complete the following and return. This form must be complete for your child to attend Boulder Knoll.

 Child’s Name: ____________________________________________

Home Phone:_____________________________________________

 

Parent 1:__________________________________________________

Cell phone: _______________________________________________

Work/other phone: ____________________________________

 

Parent 2: _________________________________________________

Cell phone:_______________________________________________

Work/other phone:___________________________________

 

Pediatrician: _____________________________________________

Phone: ____________________________________________________

 

Dentist: __________________________________________________

Phone: ___________________________________________________

 

Hospital of Choice: _____________________________________

City: _______________________________________________________

 

If a parent or guardian cannot be reached, the following emergency contacts may be used to authorize medical treatment.

 

Name: ______________________________________________________________

Phone: _____________________________________________________________

Address: ___________________________________________________________

Alternate Phone: _________________________________________________

 

Name: ______________________________________________________________

Phone: _____________________________________________________________

Address: ___________________________________________________________

Alternate Phone: _________________________________________________

 

Parents authorize certified staff to administer first aid and CPR if necessary. Parents authorize staff to call 911 for child to be treated and transported by ambulance to hospital of choice, as listed above. Parents authorize emergency contact names to authorize medical treatment.

 

______________________________________________         

 Parent 1 Signature                                     

_____________________________________________

Parent 2 Signature