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Fillable Printable Child Care Emergency Contact Information and Consent Form

Fillable Printable Child Care Emergency Contact Information and Consent Form

Child Care Emergency Contact Information and Consent Form

Child Care Emergency Contact Information and Consent Form

CHILD CARE EMERGENCY CONTACT INFORMATION AND CONSENT FORM
Child’s Name: ___________________________________________ Birth Date: __________________________________
Address: ___________________________________________________________________________________________
Parent/Guardian #1 Name: ____________________________________________________________________________
Telephone: Home ______________________Work ________________________Beeper/Cell _______________________
Parent/Guardian #1 Name: ____________________________________________________________________________
Telephone: Home ______________________Work ________________________Beeper/Cell _______________________
EMERGENCY CONTACTS (to whom child may be released if guardian is unavailable)
Name #1: __________________________________________________ Relationship: _____________________________
Telephone: Home ______________________Work ________________________Beeper/Cell _______________________
Name #2: __________________________________________________ Relationship: _____________________________
Telephone: Home ______________________Work ________________________Beeper/Cell _______________________
CHILD’S PREFERRED SOURCES OF MEDICAL CARE
Physician’s name: ___________________________________________________________________________________
Address: ________________________________________________________ Telephone: ________________________
Dentist’s name: _____________________________________________________________________________________
Address: ________________________________________________________ Telephone: ________________________
Hospital name: _____________________________________________________________________________________
Address: ________________________________________________________ Telephone: ________________________
Ambulance Service: _________________________________________________________________________________
Telephone: _________________________________
(Parents are responsible for all emergency transportation charges)
CHILD’S HEALTH INSURANCE
Insurance Plan: _______________________________________________________ ID # _________________________
Subscriber’s Name (on insurance card): _________________________________________________________________
SPECIAL CONDITIONS, DISABILITIES, ALLERGIES, OR MEDICAL EMERGENCY INFORMATION
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PARENT/GUARDIAN CONSENT AND AGREEMENT FOR EMERGENCIES:
As parent/guardian, I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive
emergency care. I will be responsible for all charges not covered by insurance. I 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 6 months.
Parent/Guardian Signature: _____________________________________________ Date: _________________________
Parent/Guardian Signature: _____________________________________________ Date: _________________________
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