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