2024-25 SJPDS Emergency Form

EMERGENCY FORM

Maryland State Department of Education- Office of Child Care
Do you participate in the Child and Adult Food Program (CACFP)?

NoYes
Meals your child will receive while in care school and childcare services (please mark all that apply, if none, leave blank).

BreakfastLunchSupperAM SnackPM SnackEvening Snack
INSTRUCTIONS TO PARENTS:
(1) Complete ALL items in this form. If a question doesn't apply please put "not applicable" or "none" as neccessary. Please sign and date where indicated.

(2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s health practitioner review that information.

NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.
Child's First Name
Child's Last Name
Birth Date

MonthDayYear
Date
Enrollment Date

MonthDayYear
Date
Hours & Days of Expected Attendance
Child’s Home Address (Street, City, State, Zip)
Parent/Guardian #1
Parent/Guardian Name

First NameLast Name
Relationship
Place of Employment
Work Phone Number
Cell Phone Number
Home Phone Number
Email
example@example.com
Parent/Guardian #2
Parent/Guardian Name

First NameLast Name
Relationship to Child
Place of Employment
Work Phone Number
Cell Phone Number
Home Phone Number
Email
example@example.com
Authorization to Pickup
Name of Person Authorized to Pick-up Child (daily)
Relationship to Child
Address (Street, City, State, Zip)
Any Changes/Additional Information
Annual Updates
Please initial and date
When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:
Emergency Contacts
Emergency Contact #1

First NameLast Name
Home Phone Number
Work Phone Number
Address (Street, City, State, Zip)
Emergency Contact #2

First NameLast Name
Home Phone Number
Work Phone Number
Address (Street, City, State, Zip)
Emergency Contact #3

First NameLast Name
Home Phone Number
Work Phone Number
Address (Street, City, State, Zip)
Child’s Physician or Source of Health Care
Telephone
Address (Street, City, State, Zip)
In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital.
Signature

Clear
Date

MonthDayYear
Date
INSTRUCTIONS TO PARENT/GUARDIAN:
(1)Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical care.

(2)If necessary, have your child’s health practitioner review the information you provide below and sign and date where indicated.
Child’s Name
Date of Birth

MonthDayYear
Date
Medical Condition(s)
Medications currently being taken by your child
Date of your child’s last tetanus shot

MonthDayYear
Date
Allergies/Reactions
EMERGENCY MEDICAL INSTRUCTIONS:
(1)Signs/symptoms to look for:
(2) If signs/symptoms appear, do this:
(3) To prevent incidents:
OTHER SPECIAL MEDICAL PROCEDURES THAT MAY BE NEEDED:
COMMENTS:
Note to Health Practitioner:
If you have reviewed the above information, please complete the following:
OCC 1214 (Revised 1/2022) - Side 2 of 2 - All previous editions are obsolete.
Should be Empty:

EMERGENCY FORM

INSTRUCTIONS TO PARENTS:

Parent/Guardian #1

Parent/Guardian #2

Authorization to Pickup

Annual Updates

Emergency Contacts

INSTRUCTIONS TO PARENT/GUARDIAN:

EMERGENCY MEDICAL INSTRUCTIONS:

Note to Health Practitioner: