Emergency Contact Form - Early Childhood Development Center

Close To My Heart

Early Childhood Development Center

1740 Van Dyke Street

St. Paul, MN 55109

651-307-1492

Emergency Contact Form

Child’s First, Middle & Last Name: _______________________________________________________________________________ Birth Date: _________________________

Mother/Guardian First, Middle & Last Name: ______________________________________________________________________ Email: _____________________________

Address: ______________________________________________________________________________________________________ Phone: _____________________________

Company Name & Address: _________________________________________________________________________________________________________________________

Hours: _______________________________________________________ Phone& Ext. ___________________

Cell Phone: __________________________________________________________________ Pager: _______________________________________

Father/Guardian First, Middle & Last Name: _____________________________________________________________ Email: ______________________________________

Address: _________________________________________________________________________________________________________ Phone: _________________________

Company Name & Address: __________________________________________________________________________________________________________________________

Hours: _______________________________________________________ Phone& Ext. __________________________

Cell Phone: __________________________________________________________________ Pager: ________________________________________

EMERGENCY CONTACTS: In case child listed above becomes ill or is injured and I(Parent/Guardian) cannot be contacted, CTMH has my permission to contact and release my

child to the custody of one of the following.

Name: ________________________________________________________________________________

Relationship: ____________________________________

Address: ______________________________________________________________________________

Phone: _________________________________________

Name: ________________________________________________________________________________

Relationship: ____________________________________

Address: ______________________________________________________________________________

Phone: _________________________________________

Name: ________________________________________________________________________________

Relationship: ____________________________________

Address: ______________________________________________________________________________

Phone: _________________________________________

Name: ________________________________________________________________________________

Relationship: ____________________________________

Address: ______________________________________________________________________________

Phone: _________________________________________

Family Physician’s Name: _______________________________________________________________

Phone: _________________________________________

Clinic Name & Address: ________________________________________________________________________________________________________________________

Child’s Health Card #: _________________________________________________________________

Hospital you prefer: ___________________________________________________________________

Are there any known illness, surgery, injuries, allergies, health or medical conditions that the Provider should be made aware of? Circle YES or NO If yes, please describe:

___________________________________________________________________________________________________________________________________________________

SPECIFIC INSTRUCTIONS OF PARENT/GUARDIAN: (i.e. allergies, ongoing medication, restrictions for treatment, etc.): ___________________________________________

___________________________________________________________________________________________________________________________________________________

PARENT’S CONSENT: The information on this form will be used in emergency situations. School personnel, CTMH employees, health service staff, bus aides and drivers will have

the information in the event of an emergency. If at any time, due to such circumstances as accident, sudden illness, or emergency and medical treatment is required, this card will be

given to the necessary personnel including a private physician, hospital, anesthetic, if necessary, or hospital. I give permission to Close To My Heart to make whatever emergency

measures as judged necessary for the care and protection of my child while under the supervision of the program. In case of medical emergency, I understand that my child will be

transported to St. Paul Children’s Hospital by the local emergency unit for treatment at my expense, if the local emergency source (police/rescue squad) deems it necessary. In the event

of accidental ingestion, I understand that Close To My Heart will contact the Poison Control Center. I give permission for the staff to administer Syrup of Ipecac to my child if directed

by the Poison Control Center. I herby authorize the program to act on my behalf in case of an emergency.

_______________________________________________________

______________________________________________________

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Signature of Parent/Guardian

Print Name

Date