Free Childcare Form

Staff Emergency Contact Form

Keep essential emergency contact and medical information available for childcare employees. Information entered here is not saved to CubbyTrack.

Staff record and emergency information requirements vary by jurisdiction and employer policy. Follow applicable childcare licensing and employment requirements.

Staff Emergency Contact Form

Childcare Employee Emergency Information

Staff Information

Staff Member's Full NamePosition / Job TitleClassroom / DepartmentPrimary Phone

Home Address

Emergency Contact 1

Full NameRelationshipPrimary PhoneAlternate Phone

Emergency Contact 2

Full NameRelationshipPrimary PhoneAlternate Phone

Medical Information

Physician / ClinicPhysician Phone

AllergiesMedical Conditions / Important Information

Emergency Notes

I confirm that the emergency contact and medical information listed above is accurate to the best of my knowledge. I will notify my employer when this information changes.

Staff Member Signature

Date

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