Other than you, who else has permission to pick up your child?

In case of an emergency, I give permission for any of the following individuals to be contacted and my child may be

Who does not have permission to pick up your child? If applicable (A copy of supporting court document must be on file)

10.9.2.6 Child Care Registration Form

Special health problems? Yes or no? If yes, specify.

Regular medications? Yes or no? If yes, specify.

Other important information Yes or no? If yes, specify.

Child's medical insurance coverage

Consent to medical care and treatment of minor children

, may be given first aid/emergency treatment by a the child care

licensee and/or qualified staff at:

When I cannot be contacted, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, health care provider, hospital or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I certify under penalty of perjury under the laws of the State of Washington that this information is true and correct.

10.9.2.6 Child Care Registration Form