Parent/Guardian's Home and Employment Information: Employer/Address:

Home/Mobile Phone Mobile Phone #:

HomePhone #: Mobile Phone #: E-Mail Address: T CENTER

Person(s) Who Will Take Responsibility for the Child in an Emergency When the Parent/Guardian Cannot be Reached: (DO NOT LEAVE BLANK) First, Last Name: First, Last Name:

Person(s) to Whom the Child may be Released: (other than parent/guardian) Name:Relation to Child:Phone #:

(The child development center selected) is required by the Nebraska Department Of Health and Human Services Child Care Licensing Unit to have a record of current immunizations for each child on file.

Consent to Contact Physician in Emergency:

In the event I cannot be reached to make arrangements, I hereby give my consent to The child development center selected to contact my family physician

Medication Competency Statement:

(Parent/Guardian Name) have determined the child development center selected staff competent to give or apply medication to my child. I understand that the child development center selected has the responsibility to assess the ability of staff to give or apply medication safely. The medication I provide will be in the original dispenser and will have the written directions printed on the dispenser. If the medication is a prescribed medication, it will have the child's full name printed on it.