Early Learning Center Emergency Information Card Form printable pdf download

EARLY LEARNING CENTER EMERGENCY INFORMATION CARD

CHILD’S FIRST NAME ____________________________

CHILD’S LAST NAME ________________________________

CHILD’S BIRTHDATE ______________________________

CHILD’S GENDER: MALE _________ FEMALE _________

CHILD’S ADDRESS ________________________________________ CITY ____________________ ZIP CODE __________

MOTHER’S INFORMATION

FATHER’S INFORMATION

FULL NAME ___________________________________

CELL PHONE ___________________________________

HOME PHONE _________________________________

WORK PHONE _________________________________

HOME ADDRESS _______________________________

CITY________________________

ZIP_____________

CITY________________________

ZIP_____________

PECIAL INTRUCTIONS AS TO HOW PARENTS/GUARDIANS CAN BE REACHED DURING HOURS OF OPERATION:

____________________________________________________________________________________________________________

PERSONS AUTHORIZED TO PICK UP CHILD OR BE CONTACTED IN CASE OF EMERGENCY IF PARENTS CANNOT BE REACHED:

NAME ________________________________________________ PHONE NUMBER _____________________________

ADDRESS ___________________________________________________________________________________

NAME ________________________________________________ PHONE NUMBER _____________________________

ADDRESS ___________________________________________________________________________________

NAME ________________________________________________ PHONE NUMBER _____________________________

ADDRESS __________________________________________________________________________________

CHILD’S DOCTOR __________________________________________ PHONE ___________________________________

ADDRESS __________________________________________________________________________

CHILD’S DENTIST __________________________________________ PHONE ___________________________________

ADDRESS __________________________________________________________________________

(Please check a choice of hospital below or write in name, address, and phone number of another choice below)

□ The Children’s Hospital. 13123 East 16

Avenue, Aurora, CO 80045. (720) 777-1234

□ Aurora Medical Center. 1501 S. Potomac St, Aurora, CO 80012. (303) 695-2771

□ Parker Adventist. 9395 Crown Crest Blvd, Parker, CO 80138. (303) 269-4000

HOSPITAL NAME _________________________________________________ PHONE _____________________

ADDRESS __________________________________________________________________________

ANY SPECIAL HEALTH CONDITIONS WE SHOULD BE INFORMED OF IN CASE OF EMERGENCY:

__________________________________________________________________________________________________

ALLERGIES _________________________________________________________________________________________

Please specify food, medication, etc. Write “none” if child has no known allergies.

We give lotions, lip ointments, and over-the-counter medication only when absolutely necessary. Topical products require a signed permission

form for school administration. Any necessary prescription or over-the-counter medications must be in the original container, labeled with the

child’s first and last name and a Physicians Authorization of Medication Form must be on file.

Authorization for emergency medical care:

I hereby authorize the staff and director of Peace With Christ Early Learning Center to give consent for any

and all necessary medical emergencies for my child.

Parent/Guardian signature ___________________________________________Date ______________

Early Learning Center Emergency Information Card Form

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