Emergency Information Card

All fields are requiered unless otherwise marked

Child's Name:    
Home Address (#, Street, City, State, Zip Code):
Home Phone: Date of Birth: Sex:
 Male Female

 

Mother or Guardian Name: Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional): Contact Telephone Number:

 

Father or Guardian Name: Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional): Contact Telephone Number:

 

I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted:
Name: Contact Telephone Number:
Name: Contact Telephone Number:
Name (optional): Contact Telephone Number:
Name (optional): Contact Telephone Number:

 

If Medical care is necessary, call:
Health Care Provider*
Name: Contact Telephone Number:
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
By filling out this form I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her health and safety. It is understood by me that the expense of this service will be accepted by me.

 

In case of injury or sudden illness, I request that this individual be called first:
Does your child have insurance coverage?  Yes No
Name of Insurance Company:

 

The following individual(s) may NOT remove my child from the facility:
Name(s) (optional):
Custody papers have been provided and are on file at the facility? (optional)  Yes No
Telephone Authorization Code (optional):

 

Medical Information

One of the following will be provided at the time of signing this document:

 

Is child allergic to food or other substances?  Yes No
If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:
Is child usually susceptible to infections and if so, what precautions need to be taken?  Yes No
If yes, list precautions:
Is child subject to convulsions and what should be our procedure if one occurs?  Yes No
If yes, list precautions:
Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?  Yes No
If yes, list precautions:
Additional comments:
Other special instructions: