Emergency Medical Care Family Day Care Licensing printable pdf download

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH

Community Based Regulation Section

EMERGENCY MEDICAL CARE

Family Day Care Licensing

Attention Provider: This information must be kept current at all times. Carry a copy of this form and the Child Health

Record during any off-premises child care activity. Please verify with the emergency medical care facility to assure that this

form is acceptable.

Child's name:___________________________________________ Birthdate:__________________

Parent’s name:__________________________________________ Emergency Tel:_____________

Address:_____________________________ Town: _____________________Zip Code:________

Allergies:______________________________________________ Last Tetanus________________

Medical Facility:_______________________________________ Phone #:______________________

Insurance Carrier and________________________________________________________________

Insurance ID:________________________________________________________________

Physician to be called in an emergency:

Name:__________________________________________ Phone #:______________________

Address:________________________________ Town________________ Zip Code:_______

I give my consent for the day care provider named_______________________________________, to

contact the above named physician if my child has a medical emergency. I understand that if my child's

physician is not available, another physician may be contacted on an emergency basis. I also give my

consent for the child care provider to seek medical attention in an emergency at

____________________________________. I will be responsible for all medical charges.

(hospital or walk-in clinic)

X______________________________________________

Signature

________________________________________________

Printed Name

_______________________

S:DivisionLicensureFamilyFieldFormsF_EmergMedCare.doc 3/16/12

Date

Phone: (860) 509-8045, Fax: (860) 509-7541

Telephone Device for the Deaf (860) 509-7191

410 Capitol Avenue - MS # 12CBR

P.O. Box 340308 Hartford, CT 06134

An Equal Opportunity Employer

Emergency Medical Care Family Day Care Licensing