Fillable Child Care Emergency Contact Information printable pdf download

Child Care Emergency Contact Information

Child’s Name: ____________________________________________ Birth date: __________________

Legal Guardian #1:

Name(s):____________________________________________________________________________

Telephone Numbers: Home: ___________________________ Work: ___________________________

Legal Guardian #2:

Name(s):____________________________________________________________________________

Telephone Numbers: Home: ___________________________ Work: ___________________________

Emergency Contacts (to whom child may be released if legal guardian is unavailable):

Name(s) #1: _________________________________________________________________________

Address: ____________________________________________________________________________

Telephone Numbers: Home: ___________________________ Work: ___________________________

Name(s) #2: _________________________________________________________________________

Address: ____________________________________________________________________________

Telephone Numbers: Home: ___________________________ Work: ___________________________

Child’s Usual Source of Medical Care

Name(s):___________________________________________ Town: __________________________

Telephone Numbers: __________________________________________________________________

Child’s Usual Source of Dental Care

Name(s):___________________________________________ Town: __________________________

Telephone Numbers: __________________________________________________________________

Child’s Health Insurance

Insurance Plan _____________________________________ Phone: __________________________

Subscriber’s Name (on insurance card): ______________________________ ID# _________________

Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations:

(attach: Special Care Plan and/or Emergency procedure for children with special needs form)

____________________________________________________________________________________

Transport Arrangement in an Emergency Situation

Ambulance service preference: _________________________________________________________

Child will be taken to: _________________________________________________________________

(Parents / guardians are responsible for all emergency transportation charges)

Parent/Legal Guardian Consent and Agreement for Emergencies

As parent / legal guardian, I give consent to have my child receive first aid by the child care staff and

receive first aid and emergency medical treatment by emergency personnel, and to be transported to

receive emergency care, if necessary. I understand that I will be responsible for all charges not covered

by insurance. I give consent for the emergency contact person listed above to act on my behalf until I am

available. I agree to review and update this information whenever a change occurs and at least every

once a year.

Parent/Legal Guardian #1 Signature: _________________________________ Date: ________________

Parent/Legal Guardian #2 Signature: _________________________________ Date: ________________

Child Care Staff Witness Signature: __________________________________ Date: _______________

Notarized by:

*Adapted from: American Academy of Pediatrics, Pa Chapter (2002) Model Child Care Health Policies, 4

Ed.

Child Care Emergency Contact Information