Emergency Contact and Family Information Questionnaire Child InformationChild's Name(Required) First Last Child's Date of Birth(Required) MM slash DD slash YYYY Child's Preferred Pronouns(Required) Child's Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Child's Allergies/Medical Conditions(Required)My Child is Currently Taking These Medications:(Required)Child's Doctor InformationChild's Doctor Name(Required) Child's Doctor Title(Required) Child's Doctor Institution(Required) Parent/Guardian Contact InformationParent/Guardian Name(Required) First Last Parent/Guardian Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone(Required)Cell Phone(Required)Email(Required) Workplace/Occupation(Required) Work Phone(Required)Add a Second Parent/Guardian Contact Information(Required) Yes No Second Parent/Guardian Contact InformationParent/Guardian Name(Required) First Last Parent/Guardian Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Cell Phone(Required)Email(Required) Workplace/Occupation(Required) Work Phone(Required)Two Local Emergency Contacts Who are Authorized to Pick Up Your ChildContact 1Name(Required) First Last Cell Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact 2Name(Required) First Last Cell Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medication ReleaseI give permission for Miss Angie's Place Staff to administer the following medications to my child:(Required)Sunscreen (Babyganics SPF 50+) Natural, DEET-free bug spray Sooth Sting Swab in case of bee/wasp stings Baby wipes in case of toileting accidentAuthorization to Act in the Event of Minor InjuryIn the event of a minor injury, such as a scrape or small cut, I authorize the staff of Miss Angie's Place Program to administer first aid for my child.(Required) I agreePermission to Transport in Case of an EmergencyI give permission for my child to be transported in the case of an emergency, such as an evacuation.(Required) I agreeAuthorization to Act in an EmergencyIn the event of a medical emergency, I authorize medical personnel to care for my child and/or transport my child to the hostpital. I authorize the administration of emergency medical treatment to my child by a duly qualified practitioner in my absence.(Required) I agreeAnimal and Pet PermissionI understand that my child may be exposed to pets and/or wild animals while playing outdoors.(Required) I agreePhoto PermissionI understand that my child's photo may be featured on MissAngiesPlace.org and/or in Miss Angie's Place marketing (email, social media, etc.). I agreeWalking Field Trip PermissionI understand that my child will participate in daily walking field trips on the grounds of Pine Island City Parks while enrolled in Miss Angie's Place for the purpose of nature play and study.(Required) I agreeAbout Your Family and ChildPlease tell us about your family's traditions and customs:(Required)What are your child's special interests?(Required)Is there any other information you would like to share with us about your child and/or your family at this time?(Required)I have read and understand the information in this form. I have indicated my consent and authorization where applicable. I understand that by submitting this form, I am confirming that the information submitted is accurate.(Required) I agreeOne-Time Registration Fee Quantity(Required) Price: $25.00 Quantity This one-time registration fee includes a Miss Angie’s Place T-Shirt. What Color Shirt Would You Like?(Required)PinkBlueOrangeGreenYellowPurpleAvailable colors are pink, blue, orange, green, yellow, and purple. What Size Would You Like?(Required)Youth SmallYouth MediumYouth LargeYouth XLSmallMediumLargeXLXXL3XL4XLSelect a size for your shirt. If you would like more than one, visit our Shop Page! Total Payment MethodPayPal CheckoutCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Share this:Click to share on Facebook (Opens in new window)Click to share on Twitter (Opens in new window)Click to print (Opens in new window)
