Form Instructions:

Please print, complete and sign this form and mail it to NLF. Mail completed forms to the following address:

Child's Name:
Date of Birth:
Home Address:
Home Phone:
Mother\Guardian Information:
Name:
Employer/School:
Address:
Work Phone:
Pager\Cell phone:
Father\Guardian Information:
Name:
Employer/School:
Address:
Work Phone:
Pager\Cell phone:
Physician to be called in an Emergency:
Name:
Address:
Phone:
Allergies or Medical Limitations:
Medi-Cal#:
Medical Record #:
Other Authorized persons who can pick up your child: (please list at least two and, if necessary, add additional names on back of this form)
Name Relationship Telephone Pager
In case of accident or emergency, I authorize a staff member of Nihonmachi Little Friends to take my child to the above-named physician or to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of my child.
Signature of parent or guardian:
Relationship to child:
Date:

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