Emergency Contact Card

Parents, the safety of your children while they are in our care is incredibly important to us. We ask that all families have current emergency contact information on file with us.

To avoid any confusion, please fill a separate form out for each child.

Is this child in the Student, Children's, or Nursery Ministry?*
- Student Ministry (6th - 12 grade)
- Children's Ministry (Kindergarten - 5th grade)
- Preschool Ministry (birth - five years old)
Student or Child's Level/Grade*
Student or Child's Name*
First Last
Preferred Name/Nickname*
Gender*
- Male
- Female
Date of Birth*
MM
DD
YYYY
Siblings
Click the + sign to add more rows.
Name Age
Mother's Name*
First Last
Cell Phone*
Mother's Home Phone
Work Phone
Father's Name*
First Last
Cell Phone
Home Phone
Work Phone
Family's Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Enter Email Confirm Email
Are you and your family members or friends of Signal Pres?
- Members
- Visitors
Student or Child's Known Allergies*
Medications*
Emergency Contact*
Please list two people who can serve as an emergency contact if a parent is not available. Click the + sign to add more rows.
Name Phone
Emergency Medical Information*
Pediatrician Phone Number Preferred Hospital
Special Concerns
Who cannot pick up your student/child?
Photo Permission*
- Yes, I give permission for the leaders of Signal Pres to photograph my student/child for church purposes.
- No, I do not give permission for the leaders of Signal Pres to photograph my student/child for church purposes.
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If your student/child uses an EPI Pen, please send in a labeled bag with your student/child, each time they come.
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I, the parent/guardian of child being registered, authorize the adult leaders of Signal Mountain Presbyterian Church, to act as my agent to consent to emergency treatment. I understand that every attempt will be made to contact the parent/guardian in the event of any emergency. I therefore assume all responsibility for decisions so made, and the emergency care or treatment secured for my child. This includes Signal Pres to administer one (1) dose of no dye liquid Benadryl in case of allergy reaction.
Disclaimer*
- Please check that you have read and agree to the above disclaimer.
Name
This field is for validation purposes and should be left unchanged.

Emergency Contact Card

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Name	Age

Name	Phone

Pediatrician	Phone Number	Preferred Hospital