Emergency Consent Card

Child's Name

Date of Birth

Address

Child lives with

Parent/Guardian Name (First & Last)

Home Phone

Cell Phone

Work Phone

Parent/Guardian Name (First & Last)

Home Phone

Cell Phone

Work Phone

Emergency Contact

Phone

Child's MD

Phone

Allergies

Medications

Child's Dentist

Phone

Care Card Number

Date Effective

Consent Form

It is the policy of this center to notify a parent or guardian when a child becomes ill or requires medical attention. Occasionally, we may be unable to reach a parent immediately and need to obtain urgent medical care for the child. In such cases, our procedure is to ensure the child is taken to the nearest emergency medical facility.

Please sign the consent below to authorize the facility staff to take appropriate action on behalf of your child. Return the signed consent to the center immediately. This consent will accompany your child to the emergency facility if required.

Emergency Transportation Consent:
I hereby give consent for my child, to be taken to the nearest emergency medical facility by ambulance or emergency vehicle if I cannot be contacted. I understand that any costs associated with emergency transportation or medical treatment will be my responsibility as the parent or guardian.

Medical Treatment Consent:
I hereby give consent for my child, to receive medical treatment as deemed necessary by qualified medical personnel.

Date Signed

Print Parent/Guardian Name

Witness

Description

Please fill out this form and click submit.