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Emergency Contact and Family Information Questionnaire

Child Information

Child's Name(Required)
MM slash DD slash YYYY
Child's Home Address(Required)

Child's Doctor Information

Parent/Guardian Contact Information

Parent/Guardian Name(Required)
Parent/Guardian Address(Required)
Add a Second Parent/Guardian Contact Information(Required)

Second Parent/Guardian Contact Information

Parent/Guardian Name(Required)
Parent/Guardian Address(Required)

Two Local Emergency Contacts Who are Authorized to Pick Up Your Child

Contact 1

Name(Required)
Address(Required)

Contact 2

Name(Required)
Address(Required)

Medication Release

Authorization to Act in the Event of Minor Injury

In 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)

Permission to Transport in Case of an Emergency

I give permission for my child to be transported in the case of an emergency, such as an evacuation.(Required)

Authorization to Act in an Emergency

In 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)

Animal and Pet Permission

I understand that my child may be exposed to pets and/or wild animals while playing outdoors.(Required)

Photo Permission

I understand that my child's photo may be featured on MissAngiesPlace.org and/or in Miss Angie's Place marketing (email, social media, etc.).

Walking Field Trip Permission

I 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)

About Your Family and Child

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)
Price: $25.00
Quantity
This one-time registration fee includes a Miss Angie’s Place T-Shirt.
Available colors are pink, blue, orange, green, yellow, and purple.
Select a size for your shirt. If you would like more than one, visit our Shop Page!
Payment Method
MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
 

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