Emergency Contact/medical Information/medical Release Form printable pdf download

WINDSOR CHRISTIAN PRESCHOOL

Emergency Contact/Medical Information/Medical Release

Child’s Name ___________________________________________ M / F

Date of Birth ________________

Street Address ________________________________________ City _____________________ Zip ___________

Home Phone ______________________________________ email address ________________________________

Father’s Name

____________________________________

_______________

Work phone

Cell phone _________________

Mother’s Name

____________________________________

_______________

Work phone

Cell phone_________________

History of any serious illnesses, operations, or injuries and if so, at what age_________________________________________

______________________________________________________________________________________________________

Is child on any medications _____If so, what and why? _________________________________________________________

_________________________

Does your child have any allergies known to you (including medication)? If none, so state

____________________________________________________________________________________________

Allergic reaction occurs through (please check):

_____ ingestion

_____ contact

_____ airborne

Is medication required? YES / NO

NOTE: Any required medication that may need to be administered at school is to be sent in to school along with a doctor’s

note requesting that school personnel give the medication. Medication (including over-the-counter) must be in the original

container and properly marked with the child’s name, directions and consent for administering.

**IMPORTANT: A CHILD WITH ANY SERIOUS FOOD ALLERGIES MUST PROVIDE TO THE

PRESCHOOL A FOOD ALLERGY ACTION PLAN SIGNED BY YOUR CHILD’S DOCTOR.**

Health Insurance Carrier ________________________________________ ID # _____________________________________

Subscriber ___________________________________________________ Relationship _______________________________

Child’s Physician ________________________________________________ Phone _________________________________

Preferred Hospital _______________________________________________________________________________________

In case of illness or emergency and we are unable to contact either parent or guardian, please list two nearby

relatives or neighbors we should contact:

Name __________________________________________ Relationship __________________Phone ____________________

In case of accident, illness, or other emergency, I request that the school contact the parent/guardian. If the school cannot reach

a parent/guardian after conscientious effort, I give permission for the school staff to call paramedics or any licensed physician

or dentist. If a life threatening emergency exists, I give permission for school staff to call paramedics immediately and then

contact parent/guardian as soon as possible thereafter. I agree to accept responsibility for the cost of any medical services.

___________________________________________________________

Parent/Legal Guardian’s Signature

Date

(Revised March, 2014)

Emergency Contact/medical Information/medical Release Form

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