Emergency Card Form

Child's Name:*
First Last
Please upload a good identification photo of your child. (You can bring one in to Appletree if you are unable to upload for some reason.)
Accepted file types: jpg, gif, png, pdf.
Child's Eye Color:*
Child's Hair Color:*
Child's Date Of Birth:*
Date Format: MM slash DD slash YYYY
Parent/Guardian 1:*
First Last
Parent/Guardian 1 Email:*
Parent/Guardian 1 Phone:*
Parent/Guardian 1 Alternate Phone:
Parent/Guardian 2:
First Last
Parent/Guardian 2 Email:
Parent/Guardian 2 Phone:
Parent/Guardian 2 Alternate Phone:
Emergency Contact Person:*
First Last
Emergency Contact Person Phone:*
Emergency Contact Person Alternate Phone:
Doctor:*
First Last
Doctor Phone:*
Child's Care Card Number:*
Child's Allergies, Medications or Concerns:
Approved Pickup Other Than Parent - FULL Name & Relationship
Signature*
By signing here you give permission for your child to be transported by ambulance in case of an emergency.
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