EMERGENCY FORM

ACP EMERGENCY INFORMATION
Child's Information
LAST NAME*
FIRST*
PREFERRED NAME*
MIDDLE INITIAL
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BIRTHDATE

MonthDayYear
Date
Guardian/Contact 1 Information

This should be the person we can contact easily on a daily basis.
GUARDIAN 1 FIRST NAME*
GUARDIAN 1 LAST NAME*
Guardian/Contact 1 Role (ie mother, father, etc)
GUARDIAN 1'S ADDRESS Same as Child's

YesNo
GUARDIAN 1 ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GUARDIAN 1 HOME TELEPHONE
GUARDIAN 1 CELL TELEPHONE
GUARDIAN 1 EMAIL
example@example.com
GUARDIAN 1 COMPANY NAME
GUARDIAN 1 WORK ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GUARDIAN 1 WORK TELEPHONE
Please enter a valid phone number.
Guardian/Contact 2 Information
GUARDIAN 2 FIRST NAME
GUARDIAN 2 LAST NAME
Guardian/Contact 2 Role (ie mother, father, etc)
GUARDIAN 2'S ADDRESS Same as Child's

YesNo
GUARDIAN 2 ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GUARDIAN 2 HOME TELEPHONE
GUARDIAN 2 CELL TELEPHONE
GUARDIAN 2 EMAIL
example@example.com
GUARDIAN 2 COMPANY NAME
GUARDIAN 2 WORK ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GUARDIAN 2 WORK TELEPHONE
Please enter a valid phone number.
EMERGENCY CONTACTS

These are persons other than parents who may be called in an emergency and are authorized to take the child from the facility. The child will not be allowed to leave with any other person without written authorization from parent or guardian. LOCAL NAMES AND TELEPHONE NUMBERS MUST BE GIVEN!!
1. Name*

First NameLast Name
Address

Street Address

CityState / Province
Phone Number*
Please enter a valid phone number.
1. RELATIONSHIP TO CHILD
2. Name*

First NameLast Name
2. Address

Street Address

CityState / Province
2. Phone Number*
Please enter a valid phone number.
2. RELATIONSHIP TO CHILD
3. Name

First NameLast Name
3. Address

Street Address

CityState / Province
3. Phone Number
Please enter a valid phone number.
3. RELATIONSHIP TO CHILD
PHYSICIAN
PHYSICIAN TELEPHONE
DENTIST
DENTIST TELEPHONE
KNOWN SENSITIVITY TO DRUGS (list drugs and describe child's reaction)
ALLERGIES
DOES YOUR CHILD HAVE ALLERGIES THAT REQUIRE MEDICATIONS?

YES (use allergy link below for pdf files of paperwork)
ALLERGY PACKET
Food(s)
Asthma (describe)
Insect Bites or Stings
Other (describe)
Medications (if taken regularly)
History of any other health concerns (e.g. seizures, chronic ear infections, diabetes):
Other significant information:
PERMISSION AGREEMENT

Throughout the years, it has been necessary to use a number of permission forms. To simplify this procedure the form has been combined on one page. Please read the following carefully. THE SIGNATURES OF BOTH PARENTS/GUARDIANS MUST APPEAR ON THE FORM TO BE VALID.
A. I hereby grant permission to publish the family’s address, cell phone #s and emails in our ACP Directory as noted on our Blackboard Connect Form:*

YESNO
B. Media/Photography Consent and Release Form.
- I understand that my child(ren) may be videoed/photographed at A Child’s Place during normal preschool hours, activities or events.
- I understand that these photographs may be used throughout the school, on ACP’s Facebook page, in local newspapers, and/or the preschool’s website.
- I understand A Child’s Place will protect my child(ren)’s identity and will not publish my child(ren)’s name if a video/photograph of my child(ren)’s is used as described above.
- I understand that such photographs shall become the property of A Child’s Place, which has the right to duplicate, reproduce, and/or make other uses as A Child’s Place deems necessary.
Yes, I confirm that I have read and understand the above and thereby give consent for use of my child(ren)’s photograph/video as described above.No, I do not wish to give consent for the use of my child(ren)’s photograph/video as described above.
C. I hereby grant permission for my child to use all of the play equipment and participate in all of the activities at A Child's Place, SCCS unless exceptions are noted here.
D. In the event of an accidental injury or illness, I understand that every effort will be made to reach me concerning my child, I hereby grant permission to A Child's Place, SCCS to take whatever emergency measures as judged necessary the care and protection of my child while under their supervision.

The procedures may include, but are not limited to the following:

1. Administer first aid

2. Call 911

3. Attempt to contact the child’s parent or guardian.

4. Attempt to call the child’s pediatrician.

5. Attempt to call the emergency back-up person listed

6. If we cannot contact the parent or the child’s physician, we will do any or all of the following:

a. Continue administering First Aid

b. Call 911 and wait for emergency crew to arrive while continuing care

c. Have the child taken to an emergency hospital in the company of a staff member, in a staff vehicle if necessary.

d. Remain with the child until the parent or guardian has arrived to take control of the situation

E. I also authorize the Director or designated staff member of A Child's Place, SCCS, to sign necessary paper permitting trained personnel to perform emergency treatment for my child at the center, at a physician’s office, or at a hospital.

F. Any expenses incurred under #6 above will be the responsibility of the child’s family.

G. Saugatuck Child Care will not be responsible for anything that may happen as a result of false information at the time of enrollment.

H. The content of your child’s folder is confidential. I grant permission to make this file immediately available to administrators or teaching staff, the child’s parent or legal guardian and regulatory authorities upon request.
Date*

MonthDayYear
Date
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian's Signature*

Clear
Should be Empty:

ACP EMERGENCY INFORMATION

Child's Information

Guardian/Contact 1 Information

Guardian/Contact 2 Information

EMERGENCY CONTACTS

ALLERGIES

PERMISSION AGREEMENT