EMERGENCY: CALL 911PARENTS’ NAMES:_______________________________________ADDRESS:_____________________________________________DAD CELL PHONE NUMBER:__________________________________MOM CELL PHONE NUMBER:_________________________________EMERGENCY CONTACT:_____________________________________CONTACT PHONE NUMBER:__________________________________BUS PHONE NUMBER:_____________________________________
CHILD NAME:______________________AGE:____________________________CHILD NAME:______________________AGE:____________________________CHILD NAME:______________________AGE:____________________________
MEALS:_________________________________________________________
BEDTIME ROUTINE:________________________________________________________________________________
RULES:_________________________________________________________
NOTES:________________________________________________________________________________________
BABYSITTER INFORMATION
HEALTH INSURANCE PROVIDER:_____________________________POLICY NUMBER:______________________________________MAILING ADDRESS:_____________________________________PHONE NUMBER:______________________________________
PRIMARY CARE DOCTOR:_________________________________ADDRESS:___________________________________________PHONE NUMBER:______________________________________
PEDIATRICIAN:_______________________________________ADDRESS:___________________________________________PHONE NUMBER:______________________________________
OB/GYN:___________________________________________ADDRESS:___________________________________________PHONE NUMBER:______________________________________
DENTAL INSURANCE PROVIDER:_____________________________POLICY NUMBER:______________________________________MAILING ADDRESS:_____________________________________PHONE NUMBER:______________________________________
DENTIST:___________________________________________ADDRESS:___________________________________________PHONE NUMBER:______________________________________
HEALTH INFORMATION
AUTO PROVIDER:______________________________________POLICY NUMBER:______________________________________MAILING ADDRESS:_____________________________________AGENT:_____________________________________________PHONE NUMBER:______________________________________
LIFE PROVIDER:_______________________________________POLICY NUMBER:______________________________________MAILING ADDRESS:_____________________________________AGENT:_____________________________________________PHONE NUMBER:______________________________________
HOMEOWNERS PROVIDER:________________________________POLICY NUMBER:______________________________________MAILING ADDRESS:_____________________________________AGENT:_____________________________________________PHONE NUMBER:______________________________________
OTHER PROVIDER:_____________________________________POLICY NUMBER:______________________________________MAILING ADDRESS:_____________________________________AGENT:_____________________________________________PHONE NUMBER:______________________________________
INSURANCE INFORMATION
SCHOOL NAME:________________________________ADDRESS:___________________________________PHONE NUMBER:______________________________PRINCIPAL:_________________________________NURSE:____________________________________BUS #:____________________________________BUS DRIVER:________________________________BUS PHONE NUMBER:___________________________
CHILD NAME:______________________________________TEACHER:________________________________________CLASSROOM:______________________________________ROOM NUMBER:____________________________________
CHILD NAME:______________________________________TEACHER:________________________________________CLASSROOM:______________________________________ROOM NUMBER:____________________________________
CHILD NAME:______________________________________TEACHER:________________________________________CLASSROOM:______________________________________ROOM NUMBER:____________________________________
SCHOOL INFORMATION
CABLE:__________________________________Account Number:_______________________________________Phone Number:________________________________________
GAS:____________________________________Account Number:_______________________________________Phone Number:________________________________________
HOUSEKEEPING:____________________________Account Number:_______________________________________Phone Number:________________________________________
INTERNET:________________________________Account Number:_______________________________________Phone Number:________________________________________
LAWNCARE:_______________________________Account Number:_______________________________________Phone Number:________________________________________
PHONE:__________________________________Account Number:_______________________________________Phone Number:________________________________________
TRASH:__________________________________Account Number:_______________________________________Phone Number:________________________________________
WATER:_________________________________Account Number:_______________________________________Phone Number:________________________________________
UTILITIES INFORMATION