​​​Little Explorers

Preschool & Childcare


Schedule a Visit or Call us Toda​y 775.833.3801

Emergency Contact Form

Schedule a visit or call us today at (775)833-3801

Copyright 2014. Little Explorers Preschool. All rights reserved.



Mother’s Name _________________________________________________________________________________

Phone # (Cell) ____________________ (home) _________________________ (work) _____________________

Please circle the best to be reached at during the day

Father’s Name _________________________________________________________________

Phone # (Cell) ____________________ (home) _________________________ (work) ____________________

 

In case of emergency, if parents cannot be contacted, we will contact the following persons (starting with #1)  Please make sure someone can be available for emergencies within 15 minutes

Name ____________________________________________________ Relationship_______________________________

Phone # (Cell) _____________________ (home) _________________________ (work) _____________________

Please circle the best to be reached at during the day

Name ____________________________________________________ Relationship_______________________________

Phone # (Cell) _____________________ (home) _________________________ (work) _____________________

Please circle the best to be reached at during the day

Name ____________________________________________________ Relationship_______________________________

Phone # (Cell) ________________________ (home) _________________________ (work) _____________________

Please circle the best to be reached at during the day


Doctors Name ________________________________________________ Phone # ________________________

Address ____________________________________________________________________________________________________________________________________________________________________________________

Dentist Name ________________________________________________ Phone # ________________________

Address ____________________________________________________________________________________________________________________________________________________________________________________

 

As the parent/legal guardian of _______________________________________________________________________________, In the event of an emergency, I give consent to Little Explorers Preschool & Childcare to seek all emergency medical and dental care prescribed by a licensed physician (MD) or dentist (DDS).  This care may be given under whatever necessary to preserve life, limb or wellbeing of this child.  I agree to pay for any services rendered or any treatment necessary.

Medical bills will be paid by     [    ] insurance              [    ] Personal Payment

Insurance Provider ______________________________________________ Policy # _______________________

 

Notes/Known Allergies: _______________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________


 

Signature _____________________________________________________    Date _______________________