Child'S Enrollment/information Form Page 2
ADVERTISEMENT
1
2Medical Alert Information (i.e., allergies, medical and/or special needs/conditions): _______________________________________
__________________________________________________________________________________________________________
List any additional information which would be beneficial for the child care provider to know about your child: __________________
__________________________________________________________________________________________________________
Preferred Physician: _________________________________________________________________________________________
Address: ___________________________________________________________ Phone: _________________________________
Preferred Hospital: ___________________________________________________________________________________________
NOTE: Physical & Immunization Record should accompany child.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------
EMERGENCY CONTACT (OTHER THAN PARENTS):
1. _________________________________________________________________________________________________________
NAME
RELATIONSHIP
PHONE
2. _________________________________________________________________________________________________________
NAME
RELATIONSHIP
PHONE
-----------------------------------------------------------------------------------------------------------------------------------------------------------------
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
If my child, _____________________________________________________________, should become ill or
CHILD’S FULL NAME
Injured at, ______________________________________________________________, I understand that the
NAME OF FACILITY/PROVIDER
Child Care Provider will: (1) Contact me immediately and (2) Contact the person (s) I have designated if I cannot be reached.
Should the provider be unable to reach me and/or the person(s) designated, they are authorized to contact my child’s physician and/or
arrange for immediate medical treatment.
The physician and/or medical facility are authorized to administer emergency medical treatment necessary to ensure the health and
safety of my child.
I will accept responsibility for payment of medical services rendered.
____________________________________________________________________________________________________________
SIGNATURE
RELATIONSHIP
DATE
(OPTIONAL)
Sworn to and subscribed before me this ________, day of _______________, 20______.
__________________________________
Notary Public, State of Florida – At Large.
My Commission Expires: ______________________
__________ who is/are personally known to me
__________ who has/have produced identification: _________________________
HC CCL 5012 (Rev 03/13)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal