EMERGENCY CONTACT / PARENTAL CONSENT FORM

55 PA CODE CHAPTERS 3270 124(ab 3270 181 & 182. 3280 124 3280 181 & 102: 3290 124 (ab 3290 181 & 182
EMERGENCY CONTACT / PARENTAL CONSENT FORM
CHILD'S NAME
BIRTHDATE

MonthDayYear
Date
ADDRESS
City, State, Zip Code
MOTHER'S NAME/LEGAL GUARDIAN
TELEPHONE NUMBER
ADDRESS(including City, State, Zip Code)
BUSINESS NAME
ADDRESS (including City, State, Zip Code)
BUSINESS TELEPHONE NUMBER
Please enter a valid phone number.
FATHER'S NAME/LEGAL GUARDIAN
ADDRESS (including City, State, Zip Code)
TELEPHONE NUMBER
BUSINESS NAME
ADDRESS (including City, State, Zip Code)
TELEPHONE NUMBER
EMERGENCY CONTACT PERSON(S)
NAME
ADDRESS (including City, State, Zip Code)
TELEPHONE NUMBER WHEN CHILD IS IN CARE
NAME
ADDRESS (including City, State, Zip Code)
TELEPHONE NUMBER WHEN CHILD IS IN CARE
NAME
ADDRESS (including City, State, Zip Code)
TELEPHONE NUMBER WHEN CHILD IS IN CARE
PERSON(S) TO WHOM CHILD MAY BE RELEASED
ADDRESS (including City, State, Zip Code)
TELEPHONE NUMBER WHEN CHILD IS IN CARE
PERSON(S) TO WHOM CHILD MAY BE RELEASED
ADDRESS (including City, State, Zip Code)
TELEPHONE NUMBER WHEN CHILD IS IN CARE
NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER
ADDRESS (including City, State, Zip Code)
TELEPHONE. NUMBER
SPECIAL DISABILITIES IF ANY)
ALLERGIES (INCLUDING MEDICATION REACTION)
MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION
MEDICATION SPECIAL CONDITIONS
ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD
HEALTH INSURANCE COVERAGE FOR CHILD or MEDICAL ASSISTANCE BENEFITS
PARENTS SIGNATURE is REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT
POLICY NUMBER (REQUIRED)
OBTAINING MEDICAL CARE

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ADMIN. OF MINOR FIRST AID PROCEDURES

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WALKS AND TRIPS

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SWIMMING

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TRANSPORTATION AT THE FACILITY

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WADING

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PERIODIC REVIEW
SIGNATURE OF PARENT or GUARDIAN

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DATE

MonthDayYear
Date
SIGNATURE OF PARENT or GUARDIAN

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DATE

MonthDayYear
Date
Should be Empty:

EMERGENCY CONTACT / PARENTAL CONSENT FORM

EMERGENCY CONTACT PERSON(S)

PERIODIC REVIEW