Fillable Printable Child Care Emergency Contact Form - Indiana
Fillable Printable Child Care Emergency Contact Form - Indiana
Child Care Emergency Contact Form - Indiana
Child Care Emergency Contact Information
Child’s Name: __________________ __________________________ Birth date: _____ _____________
Legal Guardian #1:
Name(s):____________________________________________________________________________
Telephone Numbe rs: Home: ___________________________ Work: ___________ _______________ _
Legal Guardian #2:
Name(s):____________________________________________________________________________
Telephone Numbe rs: Home: ___________________________ Work: ___________ _______________ _
Emergency Contacts (to whom child may be released if legal guardian is unavai lable):
Name(s) #1: ____ _______________ ________________________________________ ______________
Address: __________________ _______________ ______________ _______________ ______________
Telephone Numbe rs: Home: ___________________________ Work: ___________ _______________ _
Name(s) #2: ____ _______________ ________________________________________ ______________
Address: __________________ _______________ ______________ _______________ ______________
Telephone Numbe rs: Home: ___________________________ Work: ___________ _______________ _
Child’s Usual Source of Medical Care
Name(s):___ _______________ _______________ __________ Town: _______________ ___________
Telephone Numbers: ________ ____ ___ ________ ___ ________ ___ ________ ___ ____ _______ ____ ___
Child’s Usual Source of Dental Care
Name(s):___ _______________ _______________ __________ Town: _______________ ___________
Telephone Numbers: ________ ____ ___ ________ ___ ________ ___ ________ ___ ____ _______ ____ ___
Child’s Health Insurance
Insurance Plan _______ ____________ _______________ ___ Phone: ___________ _______________
Subscriber’s Name (on insurance card): __________________ ____________ ID# __ ______________ _
Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations:
(attach: Special Care Plan and/or Eme rgency procedure for children with special needs form)
____________________________________________________________________________________
____________________________________________________________________________________
Transport Ar rangement in an Emergency Situation
Ambulance service p reference: _________________________________ _______________ _________
Child will be taken to: ____ _______________ _______________ ______________ _______________ __
(Parents / guardians are responsible for all emergency transportation charg es)
Parent/Legal Guardian Consent and Agreement for Emergencies
As parent / legal guardian, I give consent to have my child receive first aid by the child care staff and
receive first aid and emergency medical treatment by emergency personnel, and to be transported to
receive emergency care, if nece s sary. I understand that I will be responsible for all charges not covered
by insurance. I give consent for the emergency contact person listed above to act on my behalf until I am
available. I agree to review and update this information whenever a change occurs and at least every
once a year.
Parent/Legal Guardian # 1 Signature: _________________________________ Date: ________________
Parent/Legal Guardian # 2 Signature: _________________________________ Date: ________________
Child Care Staff Witness Signature: _______ ___________________________ Date: _______________
Notarized by:
*Adapted from: American Academy of Pediatrics, Pa Chapter (2002) Mod el Child Care Health Policies
, 4
th
Ed.
