Emerald Crossing at Cremona County Fellowship

Street

Street 2

City

State/Province

Postal Code

Parent/Guardian First Name

Parent/Guardian Last Name

Primary Phone

Alternate Phone

Emergency Contact

Relationship to Student

Phone Number

Alternate Pick Up Permission Given by Parent/Legal Guardian

Yes, I DO give my permission for the person(s) listed to pick up my child if I am unable to be there at pick up time

No, I DO NOT give my permission for the person(s) listed to pick up my child if I am unable to be there at pick up time

Please include the person's name, relationship to the child and phone number for the person(s) with/without permission to pick up your child:

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