Emergency Information

Emergency Information Form

Child's Name *

First

Last

Main contact phone number *

Address *

Parent 1 Name *

Parent 1 Phone *

Parent 1 Alternate Phone

Parent 2 Name

Parent 2 Phone *

Parent 2 Alternate Phone

Physician

Physician Phone

Contact 1 *

Local Emergency contact

Contact 1 Phone *

Contact 2 *

Local Emergency contact

Contact 2 Phone *

Contact 3 *

Local Emergency contact

Contact 3 Phone *

Sitter Name

If child is taken to school by a sitter

Sitter Phone

Child Transport list

Child Care center licensing (N.J. 10:122-6.8(a)) requires DNPCCNS to have on file a written list from each child's parents/guardians of those individuals authorized to visit and/or take their child from school. Your child will not be permitted to be visited by or leave with any individual who is not listed here.

My/our child may be visited be and/or leave school with emergency persons listed about and the following people:

Transport 1 Name

Transport 1 Address

Transport 1 Phone

Transport 2 Name

Transport 2 Address

Transport 2 Phone

Transport 3 Name

Transport 3 Address

Transport 3 Phone

Transport 4 Name

Transport 4 Address

Transport 4 Phone

Signed (Full name of member of DNPCCNS) *

In case my child has an accident or becomes ill and my doctor is not available, I give permission for my child to be treated by the University Medical Center of Princeton Emergency Room.