Emergency Form

Instructions to parents/guardians:

1. Complete all items on this form. Sign and date where indicated.

2. If your 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.

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

Name

Address

Phone 1

Phone 2

Name

Address

Phone 1

Phone 2

Name

Address

Phone 1

Phone 2

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

Child's Name

Enrollment Date

Hours & Days of Expected Attendance

Child's Home Address

Mother/Guardian's Name

Employer/School

Business Address

Home Address (if different from above)

Work Telephone

Cellular Phone

Father's/Guardian's Name

Employer/School

Business Address

Home Address (if different from above)

Work Telephone

Cellular Phone

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

Address

Instructions to parents/guardians:

1. Complete the following items, as appropriate, if your child has a condition(s) which might require emergency care.

2. If necessary, have your child's health practitioner review the information you provide below and sign and date where indicated.

Child's Name

Birthday

Medical Condition(s)

Medications currently being taken by your child

Date of your child's last tetanus shot

Allergies/Reactions

Emergency Medical Instructions:

Signs/symptoms to look for

If signs/symptoms appear, do this

To prevent incidents

Other special medical procedures that may be needed

Comments

Note to Health Practitioner

If you have reviewed the above information, please complete the following:

Name of Health Practitioner

Date

Signature of Health Practitioner

Phone

Thanks for submitting!