Text Box: Back Text Box: Emergency Contact Information Last Name                                   First Name                                      Phone  _________________________________________________________________________ Address _________________________________________________________________________  Last Name                                  First Name                                       Phone  _________________________________________________________________________ Address  _________________________________________________________________________ Authorized to Pick-Up Last Name                                 First Name                                      Relationship to Child  ____________________________________________________________________________ Last Name                                 First Name                                      Relationship to Child  __________________________________________________________________________ Insurance Information Carrier/Provider                         Policy Number                             Group Number ___________________________________________________________________________  Chronic Illness                           Current Medications                    Allergies  __________________________________________________________________________ Other  ___________________________________________________________________________  Parent’s Signature______________________________________________________