DB-A2-4

CHILD CARE EMERGENCY CONTACT INFORMATION

Child’s Name: __________________________________________Birthdate: _____________

Home Address: ________________________________________________________

Parent or Guardian: ___________________________________________________________

Telephone Numbers: Home__________________________Work________________

Cell Phone/Pager _______________ E-mail Address: _________________________

Home Address: ________________________________________________________

Place of Employment: ______________________________Department: __________

Contact person at work (who usually knows your whereabouts):__________________

____________________________ Phone Number:____________________________

Parent or Guardian:___________________________________________________________

Telephone Numbers: Home ___________________ Work______________________

Cell Phone/Pager _______________ E-mail Address: _________________________

Home Address: ________________________________________________________

Place of Employment:_____________________________ Department:___________

Contact person at work (who usually knows your whereabouts):__________________

____________________________ Phone Number:____________________________

Emergency Contacts (when attempts to reach parents are not successful and who may pick

child up)

Name#1:______________________________________________________________

Telephone Numbers: Home ___________________ Work______________________

Name#2:_____________________________________________________________

Telephone Numbers: Home ___________________ Work______________________

Person’s Authorized to pick child up

Name:________________________________ Phone Number:___________________

Name:________________________________ Phone Number:___________________

Name:________________________________ Phone Number:___________________

Name:________________________________ Phone Number:___________________

We must have written permission for anyone other than parent/guardian to pick child

up from the center.

Child’s Usual Source of Medical Care

Physician’s Name:_____________________________________Phone #:__________

Address:______________________________________________________________

Hospital to take child in case of an emergency:________________________________

Dentist’s Name (either Child’s or Parent’s): __________________________________

Address:______________________________________________Phone #:_________

Child’s Health Insurance

Name of Insurance Plan:_________________________________________________

Certificate Number (or ID) #:______________________ Group #: _______________

Policy Holder’s Name:___________________________________________________

Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations:

_____________________________________________________________________

_____________________________________________________________________

Parent/Legal Guardian Consent and Agreement for Emergencies

As parent/legal guardian, I give consent to have my child receive first aid by facility

staff, and, if necessary, be transported to receive emergency care. I understand that I will be

responsible for all charges not covered by insurance. I agree to review and update this

information whenever a change occurs and at least once a year.

Date:__________ Parent/Guardian #1 Signature____________________________________

Date:__________ Parent/Guardian #2 Signature____________________________________

Review Date____________ Parent/Guardian Signature_______________________________

Review Date____________ Parent/Guardian Signature_______________________________

Review Date____________ Parent/Guardian Signature_______________________________