Children's Extracurricular Activity Emergency Contact Form Template

⚽🎨🎵📚

LITTLE EXPLORERS • SAFETY FIRST

Children's Extracurricular Activity
Emergency Contact Form

Help us keep your child safe, happy and supported during their activities.

♡ Child Safety ✓ Parent / Guardian Details ✦ Emergency Preparedness

Meet Your Little Star 🌟

Tell us about the child participating.

Child's First Name *

Child's Last Name *

Date of Birth *

School Grade / Year

Choose Their Adventure 🎯

Which extracurricular activity will your child attend?

Select Activity *

⚽ Sports Games & fitness 💃 Dance Movement & rhythm 🎵 Music Lessons & practice 🎨 Arts & Crafts Creative activities 📚 Academic Tutoring & clubs ✨ Other Another activity

Please Specify Activity *

Program / Club Name *

Class / Team / Group

Parent or Guardian Details 👨‍👩‍👧

Who is responsible for the child's care?

Parent / Guardian Full Name *

Relationship to Child *

Phone Number *

Email Address *

People We Can Call 📞

Please provide two trusted emergency contacts.

Primary Emergency Contact Our first point of contact

FIRST CALL

Contact Full Name *

Relationship *

Phone Number *

Secondary Emergency Contact If the first person cannot be reached

BACKUP

Contact Full Name *

Relationship *

Phone Number *

Health & Special Care 💚

Share any important information that may help us care for your child.

Does your child have allergies, medical needs or special care instructions? *

🩺 Yes, please note ✓ No known needs 💬 Discuss privately

Medical / Allergy / Care Details *

Additional Instructions (Non-Medical)

Safe Pickup Arrangements 🚗

Tell us who is authorised to collect your child after the activity.

Who may collect your child? *

👨‍👩‍👧 Parent / Guardian Only 🚗 Additional Authorised Adult

Authorised Adult Name *

Contact Number *

Parent / Guardian Confirmation ✍️

Almost done! Please review and confirm.

I confirm that the information provided is accurate and that the listed emergency contacts have been informed. * I authorise the activity organisers to contact emergency services if necessary and to notify me or my designated contacts as soon as reasonably possible. *

Parent / Guardian Signature (Typed Name) *

Date *

🔒 Your child's information should only be accessible to authorised program staff.