Emergency Information

Last Name:Brunner First Name:Alexandra
Date of Birth:Feb 7, 2006 Sex:Female
Father:James Brunner Employer:Kaelus, Inc.
Work Address:12503 E Euclid Dr Ste 7 City, State ZIPCentennial, CO 80111
Telephone:(303) 768-8080 Hours:9am - 5pm
Mobile Phone:(303) 929-4361 Contact at Work:Yes
Mother:Janet McDaniel Employer: 
Home Address:9394 Ashbury Cir #106 City, State ZIPParker, CO 80134
Telephone:(720) 851-2021 Hours:9am - 5pm
Mobile Phone:(720) 470-9070 Contact at Work:Yes
Persons to contact or who are authorized to take custody of child (other than parents) in the event of illness, injury or other emergency:
NamePhone Number(s)Relationship
Janet Goodwin(303) 589-5327Step parent
Pete Friesen(303) 886-5146Family friend
Boyd & Pat Fuller(303) 772-1128Grandparents
Lloyd & Diane McDaniel(303) 776-0419Grandparents
Jack & Betty Brunner(425) 387-3124Grandparents
   
Child's current professional care givers:
FunctionNamePhone NumberAddress
PhysicianAdvanced Pediatric Associates(303) 699-62009397 Crown Crest Blvd #330, Parker CO, 80138
HospitalParker Adventist(303) 269-40009395 Crown Crest Blvd, Parker CO, 80138
DentistBeth Nielsen DDS(303) 841-900916830 Northgate Dr #100, Parker CO, 80134
Special Health Concerns or Alergies: none
I/We do hereby authorize the adult leaders or agents of                                                                to act as agents for the undersigned; to consent to any medical or surgical diagnosis or treatment or hospital care deemed advisable by or administered by a licensed physician, in the event such help of an emergency medical nature becomes necessary.
Parent SignatureDate
Parent SignatureDate