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Special Conditions, Disabilities, Allergies, or Medical Emergency Informa tion _____ _____ Parent/Guardian Consent and Agreement As parent/guardian, I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive emergency care. I will be responsible for all charges not covered by insurance.
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emergency contact parental consent form 55 pa code chapters 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182. name of child's physician/medical care provider emergency contact person(s) person(s) to whom child may be released birth date home telephone number mobile telephone number mobile.
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CY 142 — Child Care Employee Data Sheet. CY 321 — Day Care Agreement. CY 862 — Medication Log. CY 863 — Verbal Request for Release of Child. CY 864 — Fire Drill Log. CY 866 — Incident Report Form. CY 867 — Emergency Contact/Parental Consent Form. CY 113 — Pennsylvania Child Abuse History Clearance.
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BACKPACK EMERGENCY CARD. It is important to have your emergency contact information with you in case of an emergency. Complete the cards below, cut them out around the dotted line, fold in half, and keep the Child's Card in your child's backpack and the Guardian's Card in your wallet. Make this card part of an emergency planning family night!
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Here are the five most important things to include on your child care emergency forms and why you'll need them. Child & Family Information: This basic information includes the child's name and date of birth and their parents' or guardians' names and phone numbers. This is key to verify the child's identity and who you need to reach.
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A free, printable emergency contact form. While you hope to never use them, it is imperative to have emergency contact forms on file for each child in your care so you are prepared if an emergency situation occurs. Download this template to record the following information for each child: Use this printable template to create emergency contact.
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I consent for the emergency contact person listed above to act on my behalf until I am available. Parent/Guardian Consent for Emergencies Is your child taking any medications? If so, please list and include dosing information 800.338.3884 Ł procaresoftware.com Emergency Contacts (to whom child may be released if guardians are unavailable) Name
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I grant permission for the child care program to provide or arrange for medical treatment and/or transportation to an evacuation site and/or medical facility for my child during an emergency or disaster. I grant permission for my child to be released to any of the emergency contacts designated above if I am unable to pick them up in an emergency.
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INSTRUCTIONS TO PARENTS: Complete all items on this side of the form. Sign and date where indicated. Please mark "N/A" if an item is not applicable. If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child's health practitioner review that information.
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NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER. TELEPHONE NUMBER-. ADDRESS. SPECIAL DISABILITIES (IF ANY) NOT REQUIRED FOR ENROLLMENT. ALLERGIES (INCLUDING MEDICATION REACTION) MEDICAL OR DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION. MEDICATION, IF APPLICABLE (SIGNATURE PLEASE) **.
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Title: Cy 321.qxd Author: kawatkins Created Date: 11/6/2002 7:13:26 PM
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The student emergency contact forms have the necessary information for two contacts in the event of an emergency. The form also has a section to give consent to transport the child to the nearest medical facility in emergency situations. In addition, there are sections to add the child's name and other personal information.
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release the child care provider on behalf of the family. Parents/providers will make every effort to contact the other party to inform who will be contacted and, if needed, caring for the children. PARENT AGREEMENT By signing below, I understand and agree that in case of an emergency every effort will be made to contact me.
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Daycare Emergency Contact Form Template. Looking for printable emergency contact forms to use at your daycare center, preschool or similar child-centered business? At Procare Solutions, we've been offering child care emergency contact forms, application forms, sign-in sheets, bus run sheets, and preschool activity sheets to our clients for.
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In an emergency, the child care facility has my permission to provide or obtain emergency medical treatment including transporting child by ambulance or vehicle if necessary. The parent/guardian of the child will be notified as soon as possible. Parent/Guardian Signature Date. (This form must be completed and signed annually)
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Emergency Contact/Parental Consent Form Child's Name Date of Birth Sex Address Mother/Legal Guardian Information Father/Legal Guardian Information. Microsoft Word - Emergency Contact Form.docx Author: amand Created Date: 3/28/2016 3:17:41 PM.
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