Noah's Ark Preschool
Emergency Information
Child's Information
Child's Birthdate
Source of Medical Care (Clinic)
Medical Insurance Company
Child's Medical Group #
Child's Medical Policy #
Medical Insurance Policy Holder
Source of Dental Care (Clinic)
Dental Insurance Company
Child's Dental Policy #
Child's Dental Group #
Dental Insurance Policy Holder
Source of Hospital
For emergency purposes, the closest hospital, Unity Hospital, will be used.
For non-emergencies,the parents choice below will be used.
Emergency Contacts - State of MN requires 2 contacts
Cannot be parents!!
Other persons authorized to pick up child from preschool
Electronic Signature