First Aid and Emergency Medical Care Contact

Child's Name

Date of Birth

Month

Day

Year

I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to:

Medical Facility Alternate Option

and to secure necessary medical treatment for my child.

Child's Physician Name

Address

Phone Number

Child's Allergies

Chronic Health Conditions

Emergency Contacts (In order to be contacted)

Name

Relationship to Child

Address

Cell Phone

Home Phone

Do you give permission for child to be released to this person?

Yes

Name

Relationship to Child

Address

Home Phone

Cell Phone

Do you give permission for child to be released to this person?

Yes

Name

Relationship to Child

Address

Home Phone

Cell Phone

Do you give permission for child to be released to this person?

Yes

Health Insurance Coverage

Policy #

Parent/Guardian Name

Phone

Cell

Parent/Guardian Name

Phone

Cell

Parent/Guardian Signature

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Date (Valid for One Year)

Month

Day

Year