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: _________________________
