Ms

Ms. Julie's Dayca= re

EMERGENCY CARE CONSENT FORM

Child’s_Name_____________________DOB= _____/_____/_____Age________

Address________________________________________________________=

City ________________________________State _______Zip____________

PARENT / GUARDIAN INFORMATION

Mother's Name__________________________________________________

Phone(H)__________________(W)______________= __(C)_______________

Address________________________________________________________=

______________________________________________________________<= /span>

Father's Name__________________________________________________

Phone(H)________________(W)_______________(= C)__________________

Address________________________________________________________=

______________________________________________________________<= /span>

PLEASE LIST 2 EMERGENCY CONTACTS

(1) Name_______________________________________________________

Phone(H)___________________(W)_____________= ___(C)______________

Relation________________________________________________________

Address________________________________________________________=

______________________________________________________________<= /span>

(2) Name ______________________________________________________

Phone(H) __________________(W)_______________(C)________________

Relation________________________________________________________

Address________________________________________________________=

______________________________________________________________<= /span>

CHILD’S MEDICAL INFORMATION

Doctor's Name_____________________ Phone________________________

Address ________________________________________________________<= /p>

City ___________________________State ________Zip________________

Insurance Co. ________________________Policy#_____________________<= /p>

List Medications, allergies, or any medical problems that authorized persons

or Emergency personnel should be aware of:_________= __________________

______________________________________________________________<= /span>

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 <= /o:p>

medical staff to give medical treatme= nt to the child.=

(1) Name____Ms. Juliana Hudson-Nichols_____________________________

Phone(H)____703-4= 51-2595__(W)___703-451-2595__(C)___703-380-4426__

Relation_____Daycare Provider_____________________________________

Address_____9052 Rosewall Court_________________________= __________

___________Springfield, V= a. 22152_____________________________= ____

(2) Name ______________________________________________________

Phone(H) __________________(W)_______________(C)________________

Relation________________________________________________________

Address_________________________________________________________

_____________________________________________________________

______________________________________________________________<= /span>

(3) Name ______________________________________________________

Phone(H) __________________(W)_______________(C)________________

Relation________________________________________________________

Address_________________________________________________________

_____________________________________________________________

______________________________________________________________<= /span>

Sign below to agree to the terms above and to confirm = that the information

provided above is true and accurate.=

______________________________________________________= _______________

Parent/Guardian Signature Required &= nbsp; &nbs= p; &= nbsp; Date