Upland United Methodist Church
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This Month's Series
Memory Verse Songs
Leading at Home
4:12 Youth - Jr. High
4:12 Youth - Sr. High
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Kiddie Kampus Preschool
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Information Form
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Emergency Contact
Child's Name
*
First
Last
Session
*
AM (8:30 to 11:00 AM)
PM (12:00 to 2:30 PM)
Parent/Guardian 1 Name
*
First
Last
P/G 1 Phone Number
*
Parent/Guardian 2 Name
*
First
Last
[object Object]
P/G 2 Phone Number
*
Caregiver Name
*
First
Last
[object Object]
Caregiver Phone Number
*
Please list up to 4 others who may pick-up your child (name, relationship, AND phone numbers)
*
In the event of an emergency, we will first attempt to contact parents/guardians listed above. Please provide additional emergency contacts if parents/guardians cannot be reached.
Emergency Contact 1 Name
*
First
Last
EC 1 Phone Number
*
Emergency Contact 2 Name
*
First
Last
EC 2 Phone Number
*
Child's Physician
*
First
Last
Physician's Phone Number
*
Physician's Address
*
Line 1
Line 2
City
State
Zip Code
Country
Hospital Preference
*
I hereby give my permission for Kiddie Kampus staff members to obtain the services of the doctor listed above (or another if your child's physician cannot be reached), area EMT unit, or hospital in case the named student suffers illness or accident.
Emergency Contact Agreement
*
Yes
No
Your Name
*
First
Last
Submit
✕
