About This Template
When a parent can't be reached, your staff need to know who may care for and pick up a child. This free AB 495 emergency contacts list gives California preschools, childcare programs, and schools one form for parent and alternate contacts, pickup authorization, and a yearly update. For what the law asks, see our AB 495 Family Preparedness Act checklist.
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Ready to Use
Print it or add it to your enrollment packet without reformatting.
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Clear Pickup Authority
Every contact is marked yes or no for pickup, so staff aren't guessing in a hard moment.
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Reduce Risk
Keep current, signed contact records on file before you ever need them.
What's Inside the Template
- ✓ Student information, with a box to flag siblings who are also enrolled
- ✓ Two parent or guardian contacts, each marked as authorized for pickup or not
- ✓ Room for six alternate contacts to call if parents can't be reached
- ✓ A notice asking families to update the form right away when contacts change, and at least once a year
- ✓ Signature and date lines for the parent who completes it and the staff member who receives it
- ✓ A staff reference panel for local police, fire, poison control, the nearest ER, and after-hours contacts
Get Your Free Template
Download the form and add it to your next enrollment packet.
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Common Questions
1. Why do I need to submit my information?
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We ask for your basic contact details so we can take you straight to the download, and so a member of our team can follow up if you have questions. We'll never spam you or sell your information.
2. Is this template a substitute for legal advice?
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No. This template is a helpful starting point, but it isn't legal advice. We recommend consulting your legal counsel or HR advisor to confirm exactly how AB 495 applies to your preschool or school.
3. Is this really free?
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Yes, it's 100% free. ChurchWest is committed to helping ministries and schools thrive. If you have questions after downloading, our team is happy to help at no obligation.