EMERGENCY CONTACT/PARENTAL CONSENT FORM

EMERGENCY CONTACT/PARENTAL CONSENT FORM
55 PA CODE CHAPTERS 3270.124(ab), 3270.181 & 182; 3280.124 (ab), 3280.181 & 182; 3290.124 (ab), 3290. 181 & 182

PLEASE COMPLETE EACH FIELD BELOW. USE THE TAB BUTTON TO MOVE TO THE NEXT FIELD.
CHILD’S NAME
BIRTHDATE (m/d/yyyy)

Month Day Year
Date
ADDRESS
MOTHER’S NAME/LEGAL GUARDIAN
HOME TELEPHONE NUMBER
ADDRESS
BUSINESS NAME
BUSINESS TELEPHONE NUMBER
ADDRESS
FATHER’S NAME/LEGAL GUARDIAN
HOME TELEPHONE NUMBER
ADDRESS
BUSINESS NAME
BUSINESS TELEPHONE NUMBER
ADDRESS
EMERGENCY CONTACT PERSON(S):
NAME
Phone Number

Area Code Phone Number
NAME
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
PERSON(S) TO WHOM CHILD MAY BE RELEASED:
NAME
ADDRESS
Phone Number

Area Code Phone Number
NAME
ADDRESS
Phone Number

Area Code Phone Number
NAME
ADDRESS
Phone Number

Area Code Phone Number
NAME OF CHILD’S PHYSICIAN/MEDICAL CARE PROVIDER
Phone Number

Area Code Phone Number
ADDRESS
MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION
ALLERGIES (INCLUDING MEDICATION REACTION)
Additional Information on Special Needs of Child
Medication, Special Conditions
Health Insurance Coverage for Child or Medicual Assistance Benefits
Policy Number
PARENTAL CONSENT IF REQUIRED FOR EACH ITEM BELOW. PLEASE INITIAL EACH ITEM.
OBTAINING EMERGENCY MEDICAL CARE

Clear
ADMIN. OF MINOR FIRST-AID PROCEDURES

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TRANSPORTATION BY THE FACILITY

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WALKS AND TRIPS

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SWIMMING

Clear
WADING

Clear
FINAL SIGNATURE OF PARENT OR GUARDIAN

Clear
DATE

Month Day Year
Date
FINAL SIGNATURE OF PARENT OR GUARDIAN

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DATE

Month Day Year
Date
Should be Empty:

EMERGENCY CONTACT/PARENTAL CONSENT FORM

EMERGENCY CONTACT PERSON(S):

PERSON(S) TO WHOM CHILD MAY BE RELEASED:

PARENTAL CONSENT IF REQUIRED FOR EACH ITEM BELOW. PLEASE INITIAL EACH ITEM.