Emergency Contacts: (to whom your child may be released to when parent or guardian cannot be reached)

Written permission must be on file for anyone other than a parent/guardian to pick up your child from the center.

Child's Primary Medical Care

Parent/Legal Guardian Consent and Agreement for Emergencies

As parent/guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. agree to review and update this information whenever a change occurs and at least once a year.

This form is provided to assist in your record keeping. however, it may not be all inclusive. Please adapt this form to reflect your organization's specific needs and any state or local requirements. CCA Global Partners is not engaged in the practice of law, nor can it advise you on legal matters. We strongly recommend that you review this form with appropriate advisors to assure that you are in compliance with any state or local regulation. law, or other requirement. CCA may update this form from time to time but has no obligation to do so. 2014, CCA Global Partners, Inc.