Clfn Day Care - Emergency Information Form
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1CLFN Day Care - EMERGENCY INFORMATION FORM
(Please complete all information required as this is the form we use to contact you in an emergency situation)
Child Information
: ___________________________________
___
___
___
Name
Date of Birth:
(Day)
(Month)
(Year)
____________________________
Curve Lake, Ontario K0L 1R0
Address:
(Street)
___________________________________________________________________
Address
(if residing off reserve)
______________________________________________________
CLFN Member?
If yes, please provide status number
_____________________________
_____________________
If no, please provide First Nation name:
Status Number:
__
__
_____________________________________________________
Allergies?
No
Yes (If yes, please specify type)
__________________________________________________________
Medical/Health conditions?
(please specify)
_________________________
__________________________
__________________
OHIP #
Doctor
Phone #
Legal Guardian Information
(Relationship)
______________________
______________
____________________________
Name
Email:
__________________
_____________________(
___________________________
cell)
Phone (home)
(work)
(Relationship)
______________________
______________
____________________________
Name
Email:
__________________
_____________________(
___________________________
cell)
Phone (home)
(work)
Emergency contact information must be current in cases of
Emergency Contact Information
(if Legal Guardian cannot be reached)
.
emergency i.e. power outage, illness, evacuation, etc.
The Infant Toddler Building can only sustain one hour without electricity, Preschool and SAP two hours
without electricity).
Please ensure your Emergency Contacts know they are on standby in cases of an emergency with your child while at Day Care.
: _______________________
____________________________
Emergency Contact Name
Relationship:
__________________
_____________________(
___________________________
cell)
Phone (home)
(work)
: _______________________
____________________________
Emergency Contact Name
Relationship:
__________________
_____________________(
___________________________
cell)
Phone (home)
(work)
: _______________________
____________________________
Emergency Contact Name
Relationship:
__________________
_____________________(
___________________________
cell)
Phone (home)
(work)
To whom the child can be released to:
Name: ___________________ (Relationship) ___________________ Name: ____________________ Relationship ______
Name: ___________________ (Relationship) ___________________ Name: ____________________ Relationship ______
Legal Guardian Authorization:
(I certify the above noted information to be true and current)
Name (please print)______________________ Signature ______________________
Date __________________
Name (please print)______________________ Signature ______________________
Date __________________
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