First Aid And Emergency Medical Care Consent Form printable pdf download

First Aid and Emergency Medical Care Consent Form

Child’s name_____________________

Date of Birth:____________________

Parent/Guardian 1 Name:_________________

Evening Phone:__________________

Daytime phone:_________________________

Cell Phone:_____________________

Parent/Guardian 2 Name:_________________

Evening Phone:__________________

Daytime Phone:_________________________

Cell Phone:_____________________

I authorize staff at Nature Center Preschool who are trained in the basics of first aid 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:_________________

Phone number:__________________

Address:_______________________________________________________________

Health insurance provider:______________

Policy#:________________________

Child’s allergies:_________________________________________________________

Chronic medical conditions*________________________________________________

(*If child has any chronic medical conditions diagnosed by a licensed health care practitioner, an Individual

Health Care Plan is required. Please see Director for more information.)

Required treatment including medication for chronic medical condition______________

______________________________________________________________________

Emergency Contacts/Authorized Pick up other than Parents/Guardians (In order to be contacted)

1.Name:_____________________________

Relationship to Child:_________________________

Address:_____________________________

Phone:_____________________________________

Do you give permission for child to be released to this person? ___yes

___no

Do you give permission for your child’s medical records to be released to this person? ___yes ___no

2.Name:_____________________________

Relationship to Child:_________________________

Address:_____________________________

Phone:_____________________________________

Do you give permission for child to be released to this person? ___yes

___no

Do you give permission for your child’s medical records to be released to this person? ___yes ___no

3.Name:_____________________________

Relationship to Child:_________________________

[Type text]

Address:_____________________________

Phone:_____________________________________

Do you give permission for child to be released to this person? ___yes

___no

Do you give permission for your child’s medical records to be released to this person? ___yes ___no

Parent/Guardian signature__________________________

Date_________________________

First Aid And Emergency Medical Care Consent Form

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