Child Care Emergency Contact Form - Indiana
Child Care Emergency Contact Information
Child’s Name: _____________________ ______________________ _ Birth date: __________________
Legal Guardian #1:
Name(s):____________________________________________________________________________
Telephone Numbers: Home: _____________ ______________ Work: _______ ___________ _________
Legal Guardian #2:
Name(s):____________________________________________________________________________
Telephone Numbers: Home: _____________ ______________ Work: _______ ___________ _________
Emergency Contacts (to whom child m ay be released if legal guardian is unavai lable):
Name(s) #1: ___________ ___________ ______________________________ ___________ __________
Address: ______________________ ___________ ___________ ___________ ___________ __________
Telephone Numbers: Home: _____________ ______________ Work: _______ ___________ _________
Name(s) #2: ___________ ___________ ______________________________ ___________ __________
Address: ______________________ ___________ ___________ ___________ ___________ __________
Telephone Numbers: Home: _____________ ______________ Work: _______ ___________ _________
Child’s Usual Source of Medical Care
Name(s):___________ ___________ ___________ __________ Town: _______ ___________ ________
Telephone Numbers: ____ ____ _______ ____ _______ ____ ____ _______ ____ _______ ____ _______ ___
Child’s Usual Source of Dental Care
Name(s):___________ ___________ ___________ __________ Town: _______ ___________ ________
Telephone Numbers: ____ ____ _______ ____ _______ ____ ____ _______ ____ _______ ____ _______ ___
Child’s Health Insurance
Insurance Plan ____ ___________________ ___________ ___ Phone: __________________ ________
Subscriber’ s Name (on insurance card): ______________ ___________ _____ ID# _____ ___________ _
Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations:
(attach: Special Care Plan and/or Emergency procedure for children with special needs form)
____________________________________________________________________________________
____________________________________________________________________________________
Transport Arrangement in an Emergency Situation
Ambulance service preference: __________________ ___________ ___________ ___________ ______
Child will be taken to: ____________ ___________ ___________ ___________ ___________ _________
(Parents / guardians are respon sible for all emergency tran sportation charges)
Parent/Legal Guardian Consent and Agre ement for Emergencies
As parent / legal guardian, I give consen t to have my child receive first aid by the child care staff and
receive first aid and emerg ency medical treatment by emergency personn el, and to be transported to
receive emergen cy care, if necessary. I understand that I will be responsible for all charges not covered
by insurance. I give consent for the emergency contact person listed above to act on my behalf until I am
available. I agree to review and update this information whenever a change occurs a nd at least every
once a year.
Parent/Legal Guardian #1 Signature: ____________________________ _____ Date: ________________
Parent/Legal Guardian #2 Signature: ____________________________ _____ Date: ________________
Child Care Staff Witness Signature: _________________________ _________ Date: _______________
Notarized by:
*Adapted from: American Academy of Pediatrics, Pa Chapter (2002) Model Child Care Health Policies
, 4
th
Ed.
Page 1/1
Free Download
Child Care Emergency Contact Form - Indiana PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
