Child Care Service Registration Form during Disaster Activation

Children 2 to 17 years of age. Only one child per form.

Date*

Team*

Select or enter value

Employee/Parent First Name*

Employees Last Name*

Child's Full Name*

Only one child per form.

Age*

If child is under 24 months be sure to include weeks/months (i.e. 6 weeks, 8 months, 23 months) otherwise please put just the number.

Department Name*

Extension*

Cell Phone #*

Email Address*

Department Supervisor Name*

Supervisor Contact #*

Special Needs or Concerns*

(allergies, health, medication, language, etc.)

Emergency Contact Name*

Person to contact if parents cannot be reached

Emergency Contact #*

Emergency Contact Relationship*

Acknowledgement*

• I give my permission to consult a physician or health source if I cannot be reached in an emergency situation. • I am responsible for providing all medications for my child. • I must provide the attached list of necessities for my child in order for them to be admitted for care. • I understand that some children may be relocated to an approved shelter should space become an issue.

Send me a copy of my responses

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