Shalom Kids Emergency Contact Information Form Name * First Name Last Name Date of Birth Preferred Name / Nickname Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Class / Kita Parent / Guardian 1 Name * Parent / Guardian 2 Name Trusted Adult * (Other adults that are already approved by guardians for pickup of child. Verbal or written consent will be needed for other adults not listed to pick up the child.) Trusten Adult First Name Last Name Phone (###) ### #### Trusted Adult First Name Last Name Phone (###) ### #### Trusted Adult First Name Last Name Phone (###) ### #### Pick-Up Protocols or Restrictions (Please provide any information on prohibited parties.) Medical Conditions or Concerns / Required Medications or Protocols / Allergies: Activity or Dietary Restrictions: Additional Information: Thank you!
