Emergency Contact / Parental Consent Form

Your Name*
Email*
Child's Name*
Child's Birthdate*
Date Format: MM slash DD slash YYYY
Child's Address*
Street Address Address Line 2 City State ZIP Code
Mother's Name / Legal Guardian*
Home Telephone Number*
Address*
Street Address Address Line 2 City State ZIP Code
Business Name
Business Telephone Number
Business Address
Street Address Address Line 2 City State ZIP Code
Father's Name / Legal Guardian
Home Telephone Number
Address
Street Address Address Line 2 City State ZIP Code
Business Name
Business Telephone Number
Business Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact Person( s )*
Name Telephone Number When Child Is In Care
Person( s ) To Whome Child May Be Released*
Name Address Telephone Number When Child Is In Care
Name of Child's Physician / Medical Care Provider*
Telephone Number*
Address*
Street Address Address Line 2 City State ZIP Code
Special Disabilities ( If Any )*
Allergies ( Including Medication Reaction )*
Medical or Dietary Information Necessary In An Emergency Situation*
Medication, Special Conditions*
Additional Information on Special Needs of Child*
Health Insurance Coverage For Child or Medical Assistance Benefits*
Policy Number*
I consent to:*
- Obtaining Emergency Medical Care
- Administration of Minor First Aid Procedures
- Walks and Trips
- Swimming
- Transportation By The Facility
- Wading
Signature of Parent or Guardian*
Signature of Parent or Guardian #2

Name	Telephone Number When Child Is In Care

Name	Address	Telephone Number When Child Is In Care