Parent Information — The Madison Playgroup

Current Information

Please fill out this form with the most current information.

Current Information Form

Name of Child

First Name

Last Name

Name of Parent (1)

First Name

Last Name

Name of Parent (2)

First Name

Last Name

Cell Phone (Parent 1)

(###)

###

####

Cell Phone (Parent 2)

(###)

###

####

Email (Parent 1)

Email (Parent 2)

Emergency Contact

A friend or relative nearby who can be called if a parent cannot be reached. Please list the name, phone number, address, and relationship. The person must live in New York City.

Medical Emergency Consent (please type your name in place of a signature)

If I cannot be reached in case of a medical emergency I give the Madison Playgroup permission to take my child to the nearest hospital/emergency room and authorize the directors to obtain any live saving treatment.

Pick up

Please write the names and provide a phone number for the person who will be bringing your child to school and picking them up. The Madison Playgroup must be notified in writing of any additions or changes to the list.

Allergies/Special Needs

Please notify us in writing below of any allergies or special needs your child may have.

Signed by

Please type your name below in place of a signature.

First Name

Last Name