Grace Lutheran Kids’ Place 1815 East 9800 South

Sandy, Utah
(GLKP) 84092
Phone: 801.572.3793 or
Grace Lutheran Church 801.572.6375
and School Fax: 801.553.2403

Identification and Emergency Information Form

Student name:______________________________________ Birthdate:________________
(last first MI)
Grade:______________

Child is in custody of:________________________

Mother’s Name & Full Home Address Father’s Name & Full Home Address

Home phone:___________________ Home phone:___________________

Work phone:___________________ Work phone:___________________
Cell phone:____________________ Cell phone:____________________

NAME HOME PHONE WORK PHONE CELL PHONE RELATIONSHIP TO CHILD

Additional emergency contact #1:

Additional emergency contact #2:

MEDICAL PERSONNEL TO BE CALLED IN EMERGENCY: (please note—911 will be called if necessary)

Physician: Insurance:
xxxxxxxxxxxx Policy number:
Dentist:: Insurance:
xxxxxxxxxxxx Policy number:

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY

(child will NOT be allowed to leave with any other person without written authorization from parent or guardian)
Name Home phone Work phone Cell phone Relationship to child

Parent/Guardian signature:______________________________________ Date:_______________________________

11/15/05 bk