2026-2027 Emergency Treatment/Consent Form

Emergency Information
Name of Emergency Contact
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Health Care Provider/Preferred facility:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Conditions/Allergies, if any:
Medications:
Child's Insurance:
Insurance ID #
Child's Dentist
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Child Care Provider, if applicable
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized to be released to/to pick up - People listed below must show proper identification before your child will be released from the center or the bus. No child will be released to a person under the age of 18 regardless of whether the local school district/agency allows for release to a younger person.

I give permission for my child to be released to the following people for the current program year.

**Do not enter names of parents or guardians here. Emergency Contacts must be somone who is not a parent or guardian that we can call if a parent or guardian is not available.**
First and Last Name* Phone Number* Relationship to child*
First and Last Name Phone Number Relationship to child
First and Last Name Phone Number Relationship to child
First and Last Name Phone Number Relationship to child
First and Last Name Phone Number Relationship to child

Consent for Services
Please review and give consent for each item. Giving consent means you consent to the following services while your child in enrolled in this early learning program.
Transportation to/from the center (SPECIAL EDUCATION ONLY)
Enter Initials to consent. If you DO NO consent, write "do not consent"
Developmental screenings
Enter Initials to consent. If you DO NO consent, write "do not consent"
Health Screenings (check eyes, hearing, height & weight)
Enter Initials to consent. If you DO NO consent, write "do not consent"
Dental Screenings (check teeth and gums)
Enter Initials to consent. If you DO NO consent, write "do not consent"
Use of fluoridated toothpaste
Enter Initials to consent. If you DO NO consent, write "do not consent"
Photograph/video to help train Early Learning staff
Enter Initials to consent. If you DO NO consent, write "do not consent"
Photograph/video to build partnerships with community agencies
Enter Initials to consent. If you DO NO consent, write "do not consent"
Access to and retention of State Child Profile immunization record
Enter Initials to consent. If you DO NO consent, write "do not consent"
Use of Interpreter (if applicable)
Enter Initials to consent. If you DO NO consent, write "do not consent"
I would like to share our family contact information (phone and/or email) with other families in my student's classroom.
If you answered YES, to the previous question please share the email address that you would like shared.
example@example.com
If you answered YES, to the previous question please share the phone number that you would like shared.
Please enter a valid phone number.Format: (000) 000-0000.
PLEASE REVIEW:

For your child's safety, your signature below grants trained Early Learning staff permission to provide your child with emergency treatment including First Aid and CPR. When deemed immediately necessary, medical, surgical and hospital care, treatment, and procedures will be provided by your child's regular health care provider, or by a licensed physician or hospital, if your regular health care provider cannot be reached. If you cannot be reached, transportation will be provided by ambulance, aid car, or by any of the people named above to an emergency center for treatment.
Name

First NameLast Name
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Emergency Treatment and Consent Form

Parent/Guardian Information

Emergency Information

Consent for Services