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Berean Education Center Emergency Card

Date Completed _________ Revised _________

Child’s Name __________________________ Birthdate ________ Parents’ Names _________________________ Home Address ____________________________________ City __________________________ Zip _________ Alternate Address _____________________________ City _______________________________ Zip _________ Home Phone # ____________________________ Alternate Phone # __________________________ Father’s Employer __________________________________ Phone __________________ Hours ____________ Mother’s Employer _________________________________ Phone __________________ Hours _____________

Emergency contacts - (Persons who we may contact & may pick up your child if we cannot contact you.) Name ________________________________ Phone ___________________ Relationship __________________ Name ________________________________ Phone ___________________ Relationship __________________

People other than parents who have permission to pick up and drop off your child: Name _________________________________ Phone _________________ Relationship __________________ Name _________________________________ Phone _________________ Relationship __________________ People NOT authorized to pick up your child ______________________________________________________ (OVER)

Berean Education Center Emergency Card

Date Completed _________ Revised _________

Child’s Name ___________________________ Birthdate _________ Parents’ Names _______________________ Home Address ____________________________________ City __________________________ Zip _________ Alternate Address __________________________________ City __________________________ Zip _________ Home Phone # ____________________________ Alternate Phone # __________________________ Father’s Employer _________________________________ Phone __________________ Hours ____________ Mother’s Employer _________________________________ Phone __________________ Hours ____________

Emergency contacts - (Persons who we may contact & may pick up your child if we cannot contact you.) Name ________________________________ Phone ___________________ Relationship __________________ Name ________________________________ Phone ___________________ Relationship __________________

People other than parents who have permission to pick up and drop off your child: Name _________________________________ Phone _________________ Relationship __________________ Name _________________________________ Phone _________________ Relationship __________________ People NOT authorized to pick up your child ______________________________________________________ (OVER)


Physician ________________________ Address_____________________ Phone ________________________ Dentist __________________________ Address ____________________ Phone _________________________ Medical Problems ____________________________________________________________________________ Known Allergies _____________________________________________________________________________ Berean Education Center has my permission to secure medical help, including the services of the rescue squad or the emergency room of the closest medical facility in the event of an emergency.

__________________________________________________

____________________________

Signature

Date

I have read the BEC Parent Handbook and agree to the procedures and policies within. Signature ______________________________________________

Date _________________

Any changes MUST be reported to the office as soon as they take place.

PHOTO

Physician ___________________________ Address_____________________ Phone ______________________ Dentist _____________________________ Address ____________________ Phone _______________________ Medical Problems _____________________________________________________________________________ Known Allergies ______________________________________________________________________________ Berean Education Center has my permission to secure medical help, including the services of the rescue squad or the emergency room of the closest medical facility in the event of an emergency. _______________________________________________

____________________________

Signature

Date

I have read the BEC Parent Handbook and agree to the procedures and policies _________________________________________________

____________________________

Signature

Date

Any changes MUST be reported to the office as soon as they take place.

PHOTO


BEC Emergency Card