2022-23 DCP Emergency Form

Denver Cooperative Preschool

2022-23 Emergency Form

Please be sure that these forms are filled out as completely as possible.

*If the information contained in this form should change at any time during the school year, it is your responsibility to inform the office for updating.*
Student Demographic Information
Student's Full Name:*
Student's Nickname
Gender*

MaleFemale
Date of Birth:*

MonthDayYear
Date
Student Class
Primary Parent/Guardian Information
Primary P/G Full Name:*
Primary P/G Relationship to Student:*
Primary P/G Cell Phone:*
Phone Number

Area CodePhone Number
Primary P/G Home Phone:
Primary P/G Email Address:*
example@example.com
Primary P/G Home Address:*
(P.O. Box WILL NOT be accepted here - our emergency records require a physical address)
Primary P/G Date of Birth:*

MonthDayYear
Date
Primary P/G Driver's License or Alternate ID Number:*
Primary P/G Driver's License or Alternate ID Issuing State:*
Primary P/G Occupation:*
(if primary parent/caregiver does not work outside the home, or is currently unemployed, please indicate that here)
Primary P/G Employer:*
Primary P/G Employer Address:
Primary P/G Employer Phone:
Primary P/G Work Schedule:
Primary P/G Special Instructions for Contact/Communication (e.g. call cell first, text messages ok, etc.):
Secondary Parent/Guardian Information

While this field is NOT required, if your household has a Secondary Parent/Guardian PLEASE include that information here.
Secondary P/G Full Name:
Secondary P/G Relationship to Student:
Secondary P/G Cell Phone:
Secondary P/G Home Phone:
Secondary P/G Email Address:
example@example.com
Secondary P/G Home Address:
(P.O. Box WILL NOT be accepted here - our emergency records require a physical address)
Secondary P/G Date of Birth:

MonthDayYear
Date
Secondary P/G Driver's License or Alternate ID Number:
Secondary P/G Driver's License or Alternate ID Issuing State:
Secondary P/G Occupation:
(if primary parent/caregiver does not work outside the home, or is currently unemployed, please indicate that here)
Secondary P/G Employer:
Secondary P/G Employer Address:
Secondary P/G Employer Phone:
Secondary P/G Work Schedule:
Secondary P/G Special Instructions for Contact/Communication (e.g. call cell first, text messages ok, etc.):
Parents Marital Status:

MarriedSeparatedPartneredDivorcedSingleWidow/Widower
Is there a joint custody arrangement that we should be made aware of?
Child’s Medical Provider Information
Child's Pediatrician:*
Pediatrician Address:*
Pediatrician Phone Number:*
Child's Dentist:
Dentist Address:
Dentist Phone Number:
Hospital Choice (please note - if we have to call emergency services for any reason, emergency personnel will make the ultimate determination of hospital location):*
Hospital Address:*
Hospital Phone:*
DCP maintains resources for medical homes (pediatric and family care offices) as well as pediatric dentists for young children. Please contact the office if you are in need of more information.
Child’s Medical Profile Information
Medical Insurance Provider:*
Medical Insurance Policy Number:*
DCP maintains resources regarding insurance coverage for young children and their families. Please contact the office if you are in need of more information.
Has your child had a vision screening within the last 12 months?:*

YesNo
Has your child had a hearing screening within the last 12 months?:*

YesNo
Has your child had a dental screening within the last 12 months?:*

YesNo
DCP maintains resources for vision, hearing, and dental screenings for young children. Please contact the office if you are in need of more information.
Has your child ever had a developmental screening?:*

YesNo
If your child has had a developmental screening of any kind, would you consider sharing the results with your 2022-23 classroom educators and DCP administrative team?:*

YesNoMy child has not had a developmental screening
If your child has had a developmental screening we encourage you to share the results with the classroom educators and administrative team so that we can create as supportive of an environment as possible for your child.

DCP maintains resources for referrals to developmental screenings for young children. Additionally, we try to offer in-school developmental screenings through third-party providers each school year, when possible. While these screenings are optional, many families find them to be informational and supportive. Please contact the office if you are in need of more information.
Current Short-Term Medications
(Please list any short-term medications your child is currently taking.)
Current Long-Term Medications
(Please list any long-term medications your child is currently taking.)
Special Diet - Medical
(Please explain if your child is on a special diet for medical reasons)
Chronic Health Conditions (e.g. asthma, diabetes, etc. - please describe):
PLEASE NOTE:

For certain chronic health conditions (e.g. asthma, allergies, diabetes, seizure disorders, etc.) we require a care plan to be completed by the child's healthcare provider and signed by a parent or guardian in order for your child to attend school. This care plan is kept on file in our office and reviewed monthly by the Executive Director, Assistant Director, and the school nurse. Most healthcare providers will have care plans on hand to be completed, but if you require one of these forms or have questions, please email Mary Nelson at mary@dcpplay.org.
Was your child premature at birth?*

YesNo
If you answered yes above please indicate by how many weeks:
Has your child had any serious accidents we should be made aware of?
Will your child require PRESCRIPTION medication at school? (*Please note that if you intend to have prescription medication administered to your child at DCP, additional paperwork in the form of a medical order from your child's doctor will be required.)*

YesNo
Will your child require NON-PRESCRIPTION medication at school? (*Please note that if you intend to have non-prescription medication administered to your child at DCP, additional paperwork in the form of a medical order from your child's doctor will be required.)*

YesNo
Child’s Medical Profile Information - Allergies
Does your child have any allergies?:*

Yes, my child has life-threatening allergiesYes, my child has minor allergiesNo, my child has no known allergies
Allergens (food, medication, environmental, etc.)
Please list the specific items your child is allergic to here.
Does your child have a history of anaphylaxis? (Please tell us if your child has ever experienced an anaphylactic reaction as a result of being exposed to the specific allergens above. If your child is prescribed epinephrine, please let us know if this has ever been administered.)
Medications Required? (Please indicate whether or not your child requires (or has required) the use of rescue medications in the past. Please note that if you intent to have meds kept on site at DCP, additional paperwork from your child's doctor will be required):

Yes, my child requires rescue medication for their allergies.No, my child does not require rescue medication for their allergies.
Additional Notes (Please add any other information that you think might be helpful regarding your child's allergies):
PLEASE NOTE:

If your child has allergies, we require a care plan to be completed by the child's healthcare provider and signed by a parent or guardian in order for your child to attend school. This care plan is kept on file in our office and reviewed monthly by the Executive Director, Assistant Director, and the school nurse. Most healthcare providers will have care plans on hand to be completed, but if you require one of these forms, or have questions, please email Mary Nelson at mary@dcpplay.org.
Emergency Contacts
Please list emergency contacts that we can call in the event that we are unable to reach you or your child’s secondary parent/guardian.
Emergency Contact #1 Name:*
Emergency Contact #1 Relationship:*
Emergency Contact #1 Phone:*
Emergency Contact #1 Address:*
Emergency Contact #2 Name:*
Emergency Contact #2 Relationship:*
Emergency Contact #2 Phone:*
Emergency Contact #2 Address:*
Emergency Contact #3 Name:*
Emergency Contact #3 Relationship:*
Emergency Contact #3 Phone:*
Emergency Contact #3 Address:*
Authorized Pick Up List
In this section - Please list anyone who may be authorized to pick your child up from school in addition to the Primary and Secondary Parent/Guardians, along with any special instructions for pick-up/drop-off at school.

Please note that both parents/guardians will always be allowed to pick up unless otherwise stated in this section. DCP must have a copy of any court ordered procedures related to pick up.

Fellow DCP parents that are authorized to pick-up?
Authorize Pickup #1 Name:
Authorized Pickup #1 Relationship:
Authorized Pickup #1 Phone:
Authorized Pickup #1 Address:
Authorize Pickup #2 Name:
Authorized Pickup #2 Relationship:
Authorized Pickup #2 Phone:
Authorized Pickup #2 Address:
Please list any fellow DCP parents that are authorized to pick-up your child:
Should be Empty:

Student Demographic Information

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

Child’s Medical Provider Information

Child’s Medical Profile Information

Child’s Medical Profile Information - Allergies

Emergency Contacts

Authorized Pick Up List