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, Max. file size: 256 MB.

Child's Eye Color:*

Child's Hair Color:*

Child's Date Of Birth:*

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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