Preschool Emergency Contact Form

Paperwork for *enrolled* families

Form #1 - Preschool Emergency Contact Information

ALL information on this form is required by the state of Minnesota for licensing.

  • Nickname (if any)Birth Date
  • StreetCityStateZip
  • First & Last NamePhone (###-###-####)Email
  • Please type n/a if not applicable
    First & Last NamePhone (###-###-####)Email
  • At least two contacts are required for emergency contact and alternative pickup (other than parents).
    ALL FIELDS REQUIRED for emergency contacts.
    NameRelationshipPhoneStreet Address (required)City/ State/ Zip (required)
  • NameRelationshipPhoneStreet Address (required)City/ State/ Zip (required)
  • Please type n/a if not applicable.
    Click the + symbol if you need to add more than one additional contact.
    NameRelationshipPhoneCity/ State 
    NamePhoneAddress (City/ State/ Zip)
  • Please type n/a if not applicable.
  • Please type n/a if not applicable.
    CarrierPolicy #Policy Holder Name
  • If your child has not yet seen a dentist, please include your dentist's name. We almost never need this information, but are required to collect it.
    NamePhoneAddress (City/ State/ Zip)
  • I give permission to Dodge Nature Preschool to make whatever emergency (first aid, disaster evacuation, etc.) measures are judged necessary for the care and protection of my child while under the supervision of the Preschool.

    In case of a medical/dental emergency, I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource (police or emergency medical respondent) deems it necessary.

    It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child's physician and/or other adult acting on the parent's behalf.
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  • If you would like email confirmation of this form, please enter your email address here.

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