Application For Emergency Care Form
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APPLICATION FOR EMERGENCY CARE
UAB CHILD CARE CENTER
TH
1113 15
Street South
Birmingham, Alabama 35294-4553
Phone: 934-7353
Your Name ______________________________
UAB Department and Unit __________________ Dept./Unit Extension __________________________________
Your Driver’s License Number* ________________________________
*NOTE: IF THE NUMBER IS NOT PROVIDED, WE CANNOT ACCEPT YOUR CHILD.
Your Child’s Full Name: ___________________________________ Nickname ___________________________
Age ______ Birth date _______________ Sex ______ Primary Language ______________________________
Child’s Home Address _________________________________________________________________________
Street
City
Zip
Home Telephone _____________ Business Telephone: Mother: _______________ Father: __________________
Does your child take any type of medication regularly ____ Please give name of med. ______________________
NOTE: The center will administer only those medicines prescribed by a physician. If you would like us to
administer any medications, you must fill out a separate MEDICATION form when you leave the child at the
center. No over the counter medications will be administered, unless you can provide a prescription label or a
statement from the physician’s office indicating the name, purpose, and the amount that should be administered.
Please identify any special concerns or information about your child that we will need in order to provide for
his/her safety and comfort. (Examples: Behavior difficulties, food or rest preferences, special needs of any type).
Use the back of this form if you need more space to describe.
Parent’s Signature: _________________________________________ Date: ______________________________
RELEASE AUTHORIZATION
Persons authorized to pick up your child
Name _________________________________ Relationship _______________ Daytime Phone ______________
Home Address _______________________________________________________________________________
Street
City
Zip
Home Phone
Driver’s License Number _____________________________________________
NOTE: IF THIS NUMBER IS NOT PROVIDED, WE WILL NOT RELEASE YOUR CHILD.
Name _______________________Relationship ________________ Day-time Phone: ______________________
Home Address _______________________________________________________________________________
Street
City
Zip
Home Phone
Under no circumstances will your child be released to anyone not authorized here. Persons coming to pick up your
child will have their driver’s license checked against the information provided here. Without your provision of a
driver’s license number for each authorized person we have no way to verify that the person appearing is the
person you have authorized.
Parent’s Signature: ______________________________________ Date: _________________________________
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