ELC Emergency Card

ELC Emergency Card

Medical Emergency Contacts
Please note that all fields are required. Please list both parents (if applicable) and two additional medical emergency contacts. If a field is not applicable, please type N/A.

* Child's Name

* Child's Date of Birth

Emergency Contact #1

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Emergency Contact #2

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Emergency Contact #3

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Emergency Contact #4

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

* By typing your name and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes.

I give my permission for my child to be released from the program to the people listed above. These names will be listed on our "Release To" sheet. Please note: Changes to this list must be done in writing.

* Today's date

Thu, April 25 2024 17 Nisan 5784