Child Care-Emergency Consent Form

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Please attach
CHILD CARE
child’s photo
to this form.
EMERGENCY CONSENT FORM
CCFL3, Rev 04-2009
CHILD’S NAME: _______________________________________________ BIRTHDATE: ______________________________
SURNAME
FIRST NAME(S)
YEAR/MONTH/DAY
ADDRESS: _____________________________________________________________________________________________
PARENT’S NAME: ___________________________________________ HOME PHONE: ______________________________
CELL PHONE: ______________________________________________ WORK PHONE: ______________________________
PARENT’S NAME: ___________________________________________ HOME PHONE: ______________________________
CELL PHONE: ______________________________________________ WORK PHONE:_______________________________
EMERGENCY CONTACT: _________________________ CELL PHONE: _________________ PHONE: __________________
OUT OF TOWN CONTACT: __________________________________________ PHONE: ______________________________
CHILD’S DOCTOR: _________________________________________________ PHONE: ______________________________
DATE OF MOST RECENT TETANUS SHOT:___________________________________________________________________
ALLERGIES / MEDICATIONS: ______________________________________________________________________________
CHILD’S DENTIST: _________________________________________________ PHONE: ______________________________
CARE CARD NUMBER______________________________________________
CONSENT
1)
It is the policy of this facility to notify a parent when a child is ill or needs medical attention. Occasionally we
cannot contact parents and we need to get immediate help for the child. Our procedure is to call for an
ambulance.
2)
Please sign the consent below so that we can take the appropriate action on behalf of your child. Return the
signed consent to the facility immediately. We will take this consent with us to the emergency centre.
3)
I hereby give consent for my child __________________________________________ to be taken to
the nearest emergency centre when I cannot be contacted.
4)
I hereby give consent for my child named above to receive medical treatment.
_______________________________
________________________________________________
DATE
SIGNATURE OF PARENT / GUARDIAN
________________________________________________
WITNESS
CCFL3, Rev 04-2009
Provided by VCH – Community Care Facilities Licensing

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