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: _________________________