Emergency Contact Persons
(other than parent; include relation to child; please fill out in call order)
Authorized To Pick Up
(please list names including parents/emergency contacts & relationship)
**We reserve the right to check all persons ID**
**If someone other than persons listed will be picking up child, a signed note must be sent that day**
Permission To Treat
In the event my child becomes ill or involved in an accident that requires medical treatment, I give my permission for medical personnel to treat my child. I will not hold Little Flock Baptist Church, Little Flock Parent’s Day Out or its personnel responsible. I sign this with the understanding that every attempt will have been made to contact the child’s parents and/or the emergency contacts listed above.