First Aid Emergency Consent 2020-2021

Child's First Name *

Child's Last Name *

Date of Birth *

Hospital Preferred

Physician's Name *

Physician's Address *

Physician's Phone Number *

Allergies *

Chronic Health Conditions

FIRST LOCAL EMERGENCY CONTACT

Name *

FIRST PERSON TO BE CONTACTED IN THE EVENT OF AN EMERGENCY (MUST BE LOCAL)

Relationship to Child *

Address *

Cell Phone *

Home Phone *

Do you give permission for child to be released to this person? *

yes

no

SECOND LOCAL EMERGENCY CONTACT

Name *

SECOND PERSON TO BE CONTACTED IN THE EVENT OF AN EMERGENCY (MUST BE LOCAL)

Relationship to Child *

Address *

Cell Phone *

Home Phone *

Do you give permission for child to be released to this person? *

yes

no

THIRD LOCAL EMERGENCY CONTACT

Name *

THIRD PERSON TO BE CONTACTED IN THE EVENT OF AN EMERGENCY (MUST BE LOCAL)

Relationship to Child *

Address *

Cell Phone *

Home Phone *

Do you give permission for child to be released to this person? *

yes

no

INSURANCE INFORMATION

Company Name *

Policy Number *

Parent Name *

Cell Phone *

Parent Name *

Cell Phone *

AUTHORIZATION

*

I authorize Sunshine Preschool Staff who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child and his/her medical forms to be shared with medical personnel to the nearest medical care facility and to secure necessary medical treatment for my child.

Signature *

Clear

Email Address *

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