Emergency Contact / Parental Consent Form

Your Name*

Email*

Child's Information

Child's Name*

Child's Birthdate*

Child's Address*

Street Address Address Line 2 City State ZIP Code

Parents Information

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

Emergency Contact Person( s )*

Name	Telephone Number When Child Is In Care

Person To Whome Child May Be Released

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Telephone Number When Child Is In Care*

Medical Information

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*

Consent

I consent to: Obtaining Emergency Medical Care*

Yes

I consent to: Administration of Minor First Aid Procedures*

Yes

I consent to: Walks and Trips*

Yes

I consent to: Transportation By The Facility*

Yes

I consent to: Swimming

Yes

I consent to: Wading

Yes

Signature of Parent or Guardian*

Signature of Parent or Guardian #2

Emergency Contact / Parental Consent Form

Child's Information

Parents Information

Emergency Contact

Person To Whome Child May Be Released

Medical Information

Consent

Newtown: Main Office

Doylestown

Oxford Valley