ER Contact Sheet

Question Title

* 1. Child Information

Name

Age

Date of Birth

School

Question Title

* 2. Parent #1

Name

Address

Email Address

Phone Number

Question Title

* 3. Parent #2

Name

Address

Email Address

Phone Number

Question Title

* 4. Emergency Contact (when parent above can not be reached)

Name

Address

Email Address

Phone Number

Question Title

* 5. Emergency Contact #2 (when parent above can not be reached)

Name

Address

Email Address

Phone Number

Question Title

* 6. Written permission must be on file for anyone other than a parent/guardian listed above to pick up your child from the center. Please list below the legal name as shown on a valid ID of any person allowed to pick-up your child:

Question Title

* 7. Medical Information

Allergies

Medical Conditions

Medications needed at center

Question Title

* 8. Legal Information

Are there custody forms on file

Anyone who is NOT allowed to pick-up your child

Question Title

* 9. Please sign your full name in the box below if you give consent for your child to receive first aid by staff and, if necessary, be transported to receive emergency care. By signing you understand that you will be responsible for all charged not covered by insurance, and note that you agree to review and update this information whenever a change occurs and at least once a year as per our centers licensing requirements.