Emergency Situation Form

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Email *

Child's Name *

Address *

Parent(s) or Guardian(s) Name(s) *

Best Contact Number(s) *

Emergency Contact #1 (Please list name, phone number, and relationship to child) *

Emergency Contact #2 (Please list name, phone number, and relationship to child) *

Even though emergencies are a rare occurrence, it is important for an immediate response in the event such an emergency involves your child. New York State Law therefore requires that the following permission statement be signed by the child’s parent or legal guardian:In the event of an accident or medical emergency involving my child, I hereby give my permission to Tri-Village Nursery School to provide first aid to minor injuries and to call the Delmar Rescue Squad to provide emergency care and / or transportation to the hospital choice listed in your enrollment forms. Please initial to accept and acknowledge. *

Parent Digital Signature *

Today's Date *

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