* Required Information
Emergency Contact Parental Consent Form
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
*
PARENTS SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATTE PARENTAL CONSENT
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
By submitting this form you agree to the terms of the
Privacy Policy
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