Emergency Contact/Parental Consent Form

EMERGENCY CONTACT PARENTAL CONSENT FORM

Choose Location *

Child's Name *

Child's Birthdate *

Child's Address *

Mother's Name /Legal Guardian *

Mother's Home Phone *

Mother's Home Address *

Mother's Cell Phone *

Mother's Business Name *

Mother's Business Phone *

Mother's Business Address *

Mother's Email address *

Father's Name /Legal Guardian *

Father's Home Phone *

Father's Home Address *

Father's Cell Phone *

Father's Business Name *

Father's Business Phone *

Father's Business Address *

Father's Email address *

Emergency Contact Person(s) Name *

Phone Number When Child is in Care *

Person(s) To Whom Child May Be Released *

Name *

Address (City, State, Zip) *

Phone *

Name of Child Physician/Medical Care Provider *

Phone Number *

Address *

Special Disabilities (if any) *

Allergies( including medication reaction) *

Medical/ Dietary Information Necessary In an Emergency Situation *

Medication, Special Conditions *

Additional information On Special Need of Child *

Health Insurance Coverage/ Medical Assistance Benefits for Child *

Policy Number Required *

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

Obtaining Emergency Medical Care *

Admin. of Minor First Aid Procedures *

Walks and Trips *

Swimming *

Transportation by Facility *

Wading *

PARENT'S SIGNATURE IS REQUIRED TO OFFICIATE THIS DOCUMENT
Parental or Guardian Signature *

Authorization Date *