Emergency Form

INSTRUCTION TO PARENTS:

1. Complete all items on this side of the form. Sign and date where indicated.
2. If our child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s health practitioner review that information.

NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.

First Name *

Last Name *

Date of Birth *

Month *

Day *

Year *

Enrollment Date *

Month *

Day *

Year *

Hours & Days of Expected Attendance *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Parent/Guardian

Fullname *

Relationship *

Phone Number

Place of Employment *

Fullname

Relationship

Phone Number

Place of Employment

Fullname

Relationship

Phone Number

Place of Employment

Name of Person Authorized to Pick up Child (daily) *

Relationship to Child *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Any Changes/Additional Information

ANNUAL UPDATES

Initials/Date

Month

Day

Year

Initials/Date

Month

Day

Year

When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:

Name *

Telephone

H: *

W: *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Name

Telephone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Child's Physician or Source of Health Care

Telephone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM.
Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital.

Signature of Parent/Guardian *

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Date *

Month *

Day *

Year *

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Emergency Form

EMERGENCY FORM

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