EMERGENCY CONTACT/PARENTAL CONSENT FORM

EMERGENCY CONTACT/PARENTAL CONSENT FORM
" PA CODE CHAPTERS 3270 3270 181 & - 1280 174 . 182 3290 12 sasto . 182
CHILD'S NAME
BIRTHDATE
ADDRESS
MOTHER'S NAME/LEGAL GUARDIAN
ADDRESS
HOME OR CELL PHONE NUMBER
BUSINESS NAME/ TELEPHONE NUMBER/
BUSINESS ADDRESS
FATHER'S NAME/LEGAL GUARDIAN
ADDRESS
HOME OR CELL PHONE NUMBER
BUSINESS NAME/TELEPHONE NUMBER
BUSINESS ADDRESS
EMERGENCY CONTACT # 1 NAME/PHONE NUMBER
EMERGENCY CONTACT # 2 NAME/PHONE NUMBER
PERSON(S) TO WHOM CHILD MAY BE RELEASED
ADDRESS/ TELEPHONE NUMBER WHEN CHILD IS IN CARE
PERSON TO WHOM CHILD MAY BE RELEASED
ADDRESS/ TELEPHONE NUMBER WHEN CHILD IS IN CARE
NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER
ADDRESS
TELEPHONE NUMBER
SPECIAL DISABILITIES (If any)
MEDICAL OR DIETARY INFORMATION NECESSARY IN ANY EMERGENCY SITUATION
ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD
ALLERGIES INCLUDING MEDICATION REACTION
MEDICATION, SPECIAL CONDITIONS
HEALTH ENSURANCE COVERAGE FOR CHILD, MEDICAL ASSISTANCE BENEFITS
POLICY NUMBER (REQUIRED)
PARENTS SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT
OBTAINING EMERGENCY MEDICAL CARE
ADMIN. OF MINOR FIRST- AID PROCEDURES
WALKS AND TRIPS
TRANSPORTATION BY FACILITY
PHOTOGRAPHYS FOR ADVERTISMENT PURPOSES
PHOTOGRAPHYS TO BE USED WITHIN THE FACILITY OR BRIGHTWHEEL
WADWG
PERIODIC REVIEW

THIS SECTION IS TO BE SIGNED 6 MONTHS AFTER THE ORGINAL DATE
SIGNATURE OF PARENT OR GUARDIAN
DATE

MonthDayYear
Date
SIGNATURE OF PARENT OR GUARDIAN
DATE

MonthDayYear
Date
Should be Empty: