Children, Youth, Teen Programs MCB Butler, Okinawa, Japan by KevenMealamu

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									                                                Children, Youth, & Teen Programs
                                                  MCB Butler, Okinawa, Japan
                                                     Emergency Contact Plan

Due to the transient community in which we live, this Emergency Contact Plan expires every 60 days. A new plan must be
submitted no later than the 5th day of every even-numbered month. A current plan must be maintained at the Center at all times.

Part 1 General Information
        Child’s Name (last, first)                       Date of Enrollment                        Date of Emergency Plan




                                     Sponsor’s Information                                     Spouse’s Information
Name/Rank

Duty Phone

Home Phone

Cell Phone

E-mail Address


I/We reside at:




Part 2 Emergency Care Authorization

I, ___________________________________________, parent/legal guardian of __________________________________________
                  (Parent’s Name)                                                                      (Child’s Name)
give consent for a CYTP representative or Family Child Care provider to authorize transportation of my child/youth/teen for medical
or dental care in an emergency situation where my child’s condition presents a serious or imminent threat to his/her life, health, or
well-being. I understand that a conscientious effort will be made to notify me prior to such action and the expense, if any, will be
borne by me.

_________________________________________________________________                        ___________________________________
Parent’s Signature                                                                       Date

Part 3 Pick-up Authorization
Please provide a minimum of two contacts who are authorized to pick-up your child in the event of an emergency or you are unable to
pick-up your child yourself.
                              Contact 1                             Contact 2                               Contact 3
Name

Duty Phone

Home Phone

Cell Phone

                                                              Page 1 of 2
Part 4 Family Care Plan
This section is to be completed by single or dual military families or deployable DoD Civilians. Please initial each applicable
statement.

_____ A copy of my Family Care Plan has been provided to CYTP.

_____ The information on my Family Care Plan is current.

_____ The information on my Family Care Plan is NO LONGER current and I will resubmit a new plan within the next 60 days to
avoid having my child care services suspended.

_____ I have yet to submit my Family Care Plan to CYTP. I understand that I have 60 days from my child’s date of enrollment to
submit an official copy of my plan to the Center. If I am unable to present a copy of my Family Care Plan within 60 days, I will
present a letter from my Commanding Officer requesting an extension to the deadline in order to avoid having my child care services
suspended.

If you do not have a current Family Care Plan submitted, please complete the following.

Sponsor’s absence is for duration of less than 30 days. (Must be non-deployable and available on Okinawa for stated period of time.)
Caregiver Acknowledgement
Typed or Printed Name of Caregiver                                  Residence Address of Caregiver

Signature of Caregiver

Telephone Number of Caregiver


Sponsor’s absence is for duration of greater than 30 days. (Must be non-deployable or non-military.)
Caregiver Acknowledgement
Typed or Printed Name of Caregiver                                  Residence Address of Caregiver

Signature of Caregiver or State Relationship to Child if not on
Okinawa.

Telephone Number of Caregiver


Child Escort

I agree to be responsible for accompanying and caring for the family members of __________________________________________
as an escort if evacuation from Okinawa becomes necessary.
Typed or Printed Name of Escort                                     Signature of Escort



For Dual Military Couples Only

Statement of Military Spouse: I have read my spouse’s plan and concur.

Typed or Printed Name of Spouse                                          Signature of Spouse



Part 5 Acknowledgement

I acknowledge that the information I have provided in this Emergency Contact Plan is, to the best of my knowledge, accurate.

_________________________________________________________________                              ___________________________________
Parent’s Signature                                                                             Date


                                                                  Page 2 of 2

								
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