Please provide an Emergency Contact other than parents or legal guardians
SAFARI CHAMP DROP-IN CARE CENTER PROVIDES CARE FOR KIDS 3 YEARS AND UP.
Parent's or Guardian's Information
Child Information Child #1 *
Allergies or Special Needs:
Child Information Child #2
Child Information Child #3
Child Information Child #4
Contact and Release
Name, address, and phone number of the person to call in case of an emergency if parents/guardian can not be reached:
Names and telephone numbers of persons to whom your child may be released:
In the event that I can not be reached, to make arrangements for emergency medical attention at the time of illness or accidents, I authorize Safari Champ Playcare to take my child to :
I give consent for Safari Champ to secure any and all necessary emergency medical care for my child.
By submitting this form, I agree to all of Safari Champ policies
After clicking submit, you will be forwarded to a payment screen, Authorize.net. You will receive a confirmation in an email.
Current Immunization Records must be presented upon your child's first visit or a statement documenting your child has records on file at a preschool or elementary school must be signed.
1400 East Old Settlers Blvd # 200|Round Rock, TX 78665|512-828-0000
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