Emergency Contact Form

Address

Mother/legal guardian

address

Mother's business

address

Father/legal guardian

address

Father's business

address

Emergency contact person 1

Emergency contact person 2

Person to whom child may be released 1

address 1

Person to whom child may be released 2

address 2

Name of child's physician/medical care provider

Child's physician/medical care provider telephone

Child's Physician/medical care provider address

Special disabilities (if any)

Medical or dietary information necessary in an emergency situation

Allergies (including medication reaction)

Medication, special conditions

Additional information on special needs of child

Health insurance coverage for child or medical assistance benefits

Policay number (required)

Signature date

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

Obtaining emergency medical care
Signature

Walks and trips
Signature

Transportation by the facility
Signature

Administer minor first–aid procedures
Signature

Swimming
Signature

Wading
Signature

Signature

Please leave this field empty.