EMERGENCY FORM

  • INSTRUCTION TO PARENTS
    • (1) Complete all items on this side of the 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.
    NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Street/Apt. #
  • City
  • State
  • Zip Code
  • Place of Employment
  • C:
  • H:
  • Place of Employment
  • C:
  • H:
  • Relationship to Child
  • Street/Apt. #
  • City
  • State
  • Zip Code
  • MM slash DD slash YYYY
    (Initials/Date)
  • MM slash DD slash YYYY
    (Initials/Date)
  • MM slash DD slash YYYY
    (Initials/Date)
  • MM slash DD slash YYYY
    (Initials/Date)
  • When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:
  • Street/Apt. #
  • City
  • State
  • Zip Code
  • Street/Apt. #
  • City
  • State
  • Zip Code
  • Street/Apt. #
  • City
  • State
  • Zip Code
  • Street/Apt. #
  • City
  • State
  • Zip Code
  • 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.
  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY
  • INSTRUCTIONS TO PARENT/GUARDIAN:
    1. Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical care.
    2. If necessary, have your child’s health practitioner review the information you provide below and sign and date where indicated.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • EMERGENCY MEDICAL INSTRUCTIONS:
  • Note to Health Practitioner:
  • If you have reviewed the above information, please complete the following:
  • Name of Health Practitioner
  • MM slash DD slash YYYY
    Date
  • Reset signature Signature locked. Reset to sign again
    Signature of Health Practitioner
  • Telephone Number

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