Emergency contact form

Child

• Full name
• Date of birth
• Program and group or session

Parent or guardian 1

• Name
• Relationship to child
• Cell phone
• Work phone
• Email

Parent or guardian 2

• Name
• Relationship to child
• Cell phone
• Work phone
• Email

Custody

• Custody or court orders staff should know about (attach a copy)

Emergency contacts (other than parents)

Choose adults who live or work nearby and can usually answer during program hours. An emergency contact can pick up your child only if they're also on your authorized pickup list.

• 1. Name, relationship, cell phone
• 2. Name, relationship, cell phone
• 3. Name, relationship, cell phone

Doctor and insurance

• Doctor or clinic name and phone
• Dentist name and phone
• Health insurance company
• Policy or member ID
• Preferred hospital (in an emergency, your child may be taken to the nearest one)

Health details for emergencies

• Allergies and reactions
• Medical conditions
• Medications the child takes regularly
• Anything else emergency staff should know

Emergency care consent

In an emergency, staff will call 911 if needed and contact me as soon as they can. If they can't reach me, I authorize program staff to get emergency medical care for my child, including ambulance transport and treatment by a doctor or hospital, and to share this form with the medical staff who treat my child.

Signature

• Parent or guardian printed name
• Parent or guardian signature
• Date