Child Care Emergency Form
Name of Child
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Parent/Guardian
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the parent working?
Yes
No
Work Place
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family and Emergency Contacts
Â
Other people related to the child (other family members and emergency contacts)
*
Names of persons other than parent to whom child may be released
*
Health Information
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If the child has any health conditions and/or allergies please explain
Do you want to add some medical documents?
Browse Files
Drag and drop files here
Choose a file
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of
Name of Physician/Pediatrician
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Dentist/Orthodontist:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Medical Facility
Insurance Company
Policy Number
Medical Consent
Â
I, the parent/guardian of the child stated above, authorize the childcare to get the rights of the following stuations
Routine medical care and treatment
Dental care and treatment
Emergency medical care and treatment
Hospitalization
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: