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