Child Enrollment & Emergency Medical Care Form printable pdf download

CHILD ENROLLMENT & EMERGENCY MEDICAL CARE FORM

Date of Application: ___________ Date of Enrollment: ___________ Last Day of Enrollment: ___________

Child’s Name: ______________________________________________ Child’s Date of Birth: ________________

Child’s Address: ___________________________________ City: _____________________ Zip Code _________

Mother’s Name: ___________________________________Address: ____________________________________

City: ______________________ Zip Code: ___________e-mail Address: _________________________________

Home Telephone #: (_____) ____________________ Cell #: (_____) ____________________

Mother’s Employer: __________________________________________ Work #: (_____) ___________________

Mother’s Employer Address: ____________________________ City: __________________ Zip Code _________

Father’s Name: ___________________________________Address: ____________________________________

City: ______________________ Zip Code: ___________e-mail Address: _________________________________

Home Telephone #: (_____) ____________________ Cell #: (_____) ____________________

Father’s Employer: __________________________________________ Work #: (_____) ___________________

Father’s Employer Address: ____________________________ City: __________________ Zip Code _________

*******************************************************************************************************************************

Weekly Care Schedule: (please include the

Persons permitted to remove the child from the day care

child’s hours in care for each day)

home on behalf of parent. (U

se back for additional names.)

Sunday: ____________________________

Name: ________________________________________

Monday: ____________________________

Phone #: __________________Relationship _________

Tuesday: ____________________________

***********************************************

Wednesday: _________________________

In an emergency, adults to be contacted if parent cannot

Thursday: ___________________________

be reached and to whom the child can be released.

Friday: _____________________________

se back for additional names.)

Saturday: ___________________________

Name: ________________________________________

Phone #: __________________Relationship _________

Known Allergies: _____________________________________________ Last Tetanus: _____________________

Insurance Carrier: _____________________________________________ Insurance ID: _____________________

Medical Facility: ______________________________________________ Phone #: (_____) _________________

Child’s Physician:

Name: ______________________________________________________ Phone #: (_____) __________________

Address _________________________________________City:_____________________ Zip Code: __________

Child’s Dentist:

Name: ______________________________________________________ Phone #: (_____) __________________

Address _________________________________________City:_____________________ Zip Code: __________

I give my consent for the day care provider named __________________________________, to contact the above

named physician or dentist if my child has a medical emergency. I understand that if my child’s physician or dentist is

not available, another physician or dentist may be contacted on an emergency basis. I also give my consent for the

child care provider to seek medical attention in an emergency at _________________________________. I will be

responsible for all medical charges.

(hospital or walk-in clinic)

(Provider’s name) ____________________________, my child care provider, has my permission to transport my child

if necessary, when my child is in care.

Is your child related to the person providing his/her child care? ☐No

☐Yes, if yes, what is the relationship?

(Relationship – grandchild, niece, nephew, sibling, son or daughter by blood, adoption or marriage)_____________

The provisions outlined on this form have been worked out in consultation with me and have my approval.

Signature of Parent or Guardian: ______________________________________ Date: _______________________

Attention Provider: This information must be kept current at all times. Carry a copy of this form and the Child Health

Record during any off-premises child care activity. Please verify with the emergency medical care facility to assure

that this form is acceptable. This form must be kept on file for one year after the child is no longer enrolled in the child

care home.

Child Enrollment & Emergency Medical Care Form

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