Emergency Information

* = Required Information
Student's Name*
Address*
Tel*
Where parents can be reached if not at home?
Mother Name*
Tel*
Father Name*
Tel*
List two neighbors or nearby relatives who will assume temporary care of your child in case you can not be reached.
Name
Address
Tel
Name
Address
Tel
Date : 10/07/2024
In case of accident or serious illness, I request the school to contact me, if the school is unable to reach me, I authorize the school to call the physician indicated below and to follow his instructions, if it is impossible to contact this physician, the school may make whatever arrangements seem necessary.
Name of parents or guardians*
Remarks
Allergies
May aspirin be given or tylenol
- Yes
- No
Other conditions
Physician's Name
Address
Office Tel
Other Tel
Security Code

	160 Woodbine St. Bergenfield, NJ 07621
	Phone: 201-385-7500
	Email: contactus@ganyaldenutots.com

Where parents can be reached if not at home?