Emergency Medical & Transportation Agreement

Emergency Medical & Transportation Agreement
Child's Full Name:
D.O.B.

MonthDayYear
Date
Mother's Name:
Cell Phone:
Format: (000) 000-0000.
Work Address:
Work Phone:
Format: (000) 000-0000.
Father's Name:
Cell Phone:
Format: (000) 000-0000.
Work Address:
Work Phone:
Format: (000) 000-0000.
Emergency Contact:
Phone:
Format: (000) 000-0000.
Address:
Relationship:
Child's Doctor:
Phone:
Format: (000) 000-0000.
Allergies:
Current Prescribed Medication:
Child's Special Medical Needs and Conditions:
This center uses the nearest hospital as an emergency facility, that hospital is Southern Regional.
Located at 11 Upper Riverdale Rd, Riverdale, GA 30274.
Name of School:
Address:
Phone:
Format: (000) 000-0000.
Time Child Needs To Be Dropped Off By:
A.M. Picked Up By:
P.M. Mon-Fri
Do You Need Home Transportation? Yes/No If yes, Morning_ _, Afternoon
Monday-Friday
From What Address?
What is the latest we may pick up in the morning?
a.m. Earliest in the afternoon?
If transportation is not needed, Sunshine Playschool must be notified before 12:00pm or a $5 inconvenience fee will be charged to your account. I authorize Sunshine Playschool and Safe Haven Learning Academy to transport the child listed above to and from the school listed above. I also understand that Sunshine Playschool and Safe Haven Learning Academy have a transportation agreement to provide transportation between the two schools. If you do not want your child transported by the two schools, please do not complete this form. In the event that my child needs emergency care and I can not be contacted, I authorize Sunshine Playschool to act in the best interest of my child. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.
Parent Signature:
Date:

MonthDayYear
Date
Should be Empty: