Open 24 hours | Mon – Fri Saturdays open till 10 pm | Closed Sundays

Emergency Contact Form

CHILD'S NAME
Birthdate
Address
MOTHER'S NAME/LEGAL GUARDIAN
Home Telephone Number
Address
Business Name
Business Telephone Number
Address
FATHER'S NAME/LEGAL GUARDIAN
Home 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 Name Name
Address Address Address
Telephone Number Telephone Number Telephone Number
NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER
Telephone Number
Address
Special Disabilities (If Any)
Allergies (Including Medication Reaction)
Medical or Dietary Information Necessary in an Emergency Situation
Medication Special Conditions
Additional Information on Special Needs of Child
Health Insurance Coverage for Child or Medical Assistance Benefits
Policy Number (Required)
PARENT'S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT
OBTAINING EMERGENCY MEDICAL CARE
Walks and Trips Transportation by the Facility
ADMIN. OF MINOR FIRST - AID PROCEDURES
Swimming Wading

PERIODIC REVIEW

SIGNATURE OF PARENT or GUARDIAN SIGNATURE OF PARENT or GUARDIAN
Date

Date