Ms. Julie's Daycare
EMERGENCY CARE CONSENT FORM
Child’s_Name_____________________DOB_____/_____/_____Age________
Address________________________________________________________
City
________________________________State _______Zip____________
PARENT
/ GUARDIAN INFORMATION
Mother's
Name__________________________________________________
Phone(H)__________________(W)________________(C)_______________
Address________________________________________________________
______________________________________________________________
Father's
Name__________________________________________________
Phone(H)________________(W)_______________(C)__________________
Address________________________________________________________
______________________________________________________________
PLEASE
LIST 2 EMERGENCY CONTACTS
(1)
Name_______________________________________________________
Phone(H)___________________(W)________________(C)______________
Relation________________________________________________________
Address________________________________________________________
______________________________________________________________
(2)
Name ______________________________________________________
Phone(H)
__________________(W)_______________(C)________________
Relation________________________________________________________
Address________________________________________________________
______________________________________________________________
CHILD’S
MEDICAL INFORMATION
Doctor's
Name_____________________ Phone________________________
Address
________________________________________________________
City
___________________________State ________Zip________________
Insurance
Co. ________________________Policy#_____________________
List
Medications, allergies, or any medical problems that authorized persons
or
Emergency personnel should be aware of:___________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
AUTHORIZED
PERSONS TO PICK UP CHILD (Other Than Parent)
I,____________________________(Parent/Guardian),
authorize the following
persons to accompany the child to emergency facilities in
the case of a serious
injury or illness to the child. Authorization also gives consent for emergency
medical staff to give medical treatment
to the child.
(1)
Name____Ms. Juliana Hudson-Nichols_____________________________
Phone(H)____703-451-2595__(W)___703-451-2595__(C)___703-380-4426__
Relation_____Daycare Provider_____________________________________
Address_____9052 Rosewall Court___________________________________
___________Springfield,
(2)
Name ______________________________________________________
Phone(H)
__________________(W)_______________(C)________________
Relation________________________________________________________
Address_________________________________________________________
_____________________________________________________________
______________________________________________________________
(3)
Name ______________________________________________________
Phone(H)
__________________(W)_______________(C)________________
Relation________________________________________________________
Address_________________________________________________________
_____________________________________________________________
______________________________________________________________
Sign below to agree to the terms above and to confirm that
the information
provided above is true and accurate.
_____________________________________________________________________
Parent/Guardian
Signature Required Date