Ewa Plains Enrichment Preschool ER contact form
SECTION 1: Legal Person Authorizations Name of Parent or Guardian Completing This Form
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First and Last Name of Primary Parent to Contact
Cell/ work and best contact numberS
First and Last Name of Child(ren)
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Allergies, Asthma or noted medical history list here for Emergency Room
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Child’s Physician Name
Doctor office Number
EpI PEN needed, yes or no?
Provided PEN, yes or no or NOT NEEDED
Allergies and types of conditions ( Asthma)
Section 2: Consent for Medical Care and Treatment
Second Parent & Best Contact Number
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Section 3: Emergency Contact Information
Please list two contacts cases of an emergency and for when we cannot reach either parent. You may list Ms Jessica Luning.
If I cannot be contacted in the event of an emergency, I authorize and consent to these emergency contacts to make medical decisions for my child on my behalf this includes any emergency medical care, treatment, or procedure to be performed for my child by a licensed physician, health care provider, or EMT as they deem necessary to safeguard my child's health. I wave my right, if my spouse and I are not reachable and consent for such treatments. I also give permission for my child to be transported by ambulance to an emergency center for treatment.
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Emergency Contact 1
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First Name
Last Name
Relationship to child
Best Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
First Name
Last Name
Relationship to child
Best Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
The above listed people are authorized to pick-up my child from care and may be contacted in case of an emergency or illness if I cannot be reached. I understand if I want to add other family members I can attach a written note .
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