First Aid And Emergency Medical Care Consent Form
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1Wollaston Child Care Center
THE COMMONWEALTH OF MASSACHUSETTS
Department of Early Education and Care
FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM
Child's Name: _______________________________ Date of Birth: ___________________
I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first
aid/CPR when appropriate.
I understand that every effort will be made to contact me in the event of an emergency requiring medical
attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to
the nearest medical care facility and/or to ________________________, and to secure necessary medical
treatment for my child.
Child's Physician Name: ________________________________________________________
Address: ____________________________________________________________________
Phone Number: _______________________
Child's Allergies: ______________________________________________________________
Chronic Health Conditions: ______________________________________________________
Emergency Contacts (In order to be contacted)
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No______
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No_____
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No___
Health Insurance Coverage___________________________________ Policy #________________
Parent/Guardian Name: ________________________________ Phone__________ Cell___________
Parent/Guardian Name: ________________________________ Phone__________ Cell___________
___________________________________________
_________________________
Parent /Guardian Signature
Date (valid for one year)
SG/LG/SAEmergencyMedicalConsent20100122
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