Emergency Contact Parental Consent Form

* Required Information

Child's Name *

Birth Date

Address *

Mother's Name/Legal Guardian

Home Telephone Number

Email Address *

Mobile Telephone Number

Address

Business Name

Business Telephone Number

Address

Father's Name/Legal Guardian

Home Telephone Number

Email Address

Mobile Telephone Number

Address

Business Name

Business Telephone Number

Address

Emergency Contact Person(s)

Name

Telephone Number When Child Is In Care

Name

Telephone Number When Child Is In Care

Name

Telephone Number When Child Is In Care

Person(s) To Whom Child May Be Released

Name

Address

Telephone Number When Child Is In Care

Name

Address

Telephone Number When Child Is In Care

Name

Address

Telephone Number When Child Is In Care

Name of Child's Physical/Medical Care Provider

Telephone Number

Address

Special Disablities (If Any)

Allergies(Including Medication Reactions)

Special Disablities (If Any)

Allergies(Including Medication Reactions)

Medical or Dietary Information Necessary in an Emergency Situation

Medical, Special Conditions

Additional Information on Special needs of Child

Health Insurance Coverage for Child or Medical Assistance Benefits

Policy Number *

Obtaining Emergency Medical Care

Admin of Minor First-Aid Procedures

Walks and Trips

Swimming

Transportation By The Facility

Wading

Periodic Review

Signature of Parent or Guardian

Date

Signature of Parent or Guardian

Date

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