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    Child Care Emergency Contact Form Template

    Uploaded by

    Philip S. Gongar
    This document contains an emergency contact form for a child's daycare. It requests information about the child and primary and secondary guardians, including names, contact details, employers, and relationships to the child. Emergency contacts are also listed. Medical information is gathered, such as conditions, medications, doctors, insurance, and consent for emergencies. The form collects signatures from parents/guardians.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Child Care Emergency Contact Form Template

    Uploaded by

    Philip S. Gongar
    47 views2 pages
    This document contains an emergency contact form for a child's daycare. It requests information about the child and primary and secondary guardians, including names, contact details, employers, and relationships to the child. Emergency contacts are also listed. Medical information is gathered, such as conditions, medications, doctors, insurance, and consent for emergencies. The form collects signatures from parents/guardians.

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    Child_Care_Emergency_Contact_Form___Template

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    This document contains an emergency contact form for a child's daycare. It requests information about the child and primary and secondary guardians, including names, contact details, employers, and relationships to the child. Emergency contacts are also listed. Medical information is gathered, such as conditions, medications, doctors, insurance, and consent for emergencies. The form collects signatures from parents/guardians.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    47 views2 pages

    Child Care Emergency Contact Form Template

    Uploaded by

    Philip S. Gongar
    This document contains an emergency contact form for a child's daycare. It requests information about the child and primary and secondary guardians, including names, contact details, employers, and relationships to the child. Emergency contacts are also listed. Medical information is gathered, such as conditions, medications, doctors, insurance, and consent for emergencies. The form collects signatures from parents/guardians.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Child Care Emergency Contact

    Emergency Contact Form

    Child’s Information
    Child’s Full Name Name Child Prefers to be Called

    Date of Birth Age


    [ ] Male [ ] Female

    Primary Guardian’s Information


    Primary Guardian’s Name

    Home Address

    Cell Phone Home Phone Email Address

    Name of Employer Work Phone

    Relationship to Child Best Way to Reach You

    Secondary Guardian’s Information


    Secondary Guardian’s Name

    Home Address

    Cell Phone Home Phone Email Address

    Name of Employer Work Phone

    Relationship to Child Best Way to Reach You

    Page 1 of 2 800.338.3884 • procaresoftware.com


    Child Care Emergency Contact

    Emergency Contacts
    (to whom child may be released if guardians are unavailable)

    1st Contact

    Name Relationship

    Cell Phone Home Phone Work Phone

    2nd Contact

    Name Relationship

    Cell Phone Home Phone Work Phone

    Medical Information
    Medical Conditions and/or Allergies

    Is your child taking any medications? If so, please list and include dosing information

    Primary Doctor’s Name Phone

    Address

    Dentist's Name Phone

    Address

    Preferred Hospital Phone

    Address

    Health Insurance Provider Phone

    Group Number ID

    Parent/Guardian Consent for Emergencies


    As parent/guardian, I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive emergency care.
    I will be responsible for all charges not covered by insurance. I consent for the emergency contact person listed above to act on my behalf until I am available.

    Parent / Guardian Signature Date

    Page 2 of 2 800.338.3884 • procaresoftware.com

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