Emergency Contact Form

EMERGENCY CONTACT FORM

Child’s Name

Date of Birth

Child's Address

EMERGENCY CONTACT INFO

Parent/Guardian #1

Parent/Guardian #2

Name__________________________________________________________________

Name_____________________________________________________________

Address (if different than child's)

Address (if different than child's and guardian #1)

______________________________________________________________________

_______________________________________________________________________

______________________________________________________________________

_______________________________________________________________________

E-mail _________________________________________________________________

E-mail _________________________________________________________________

Phone (c) ____________________________ Phone (w) ________________________

Phone (c) ____________________________ Phone (w) ________________________

Phone (h)_____________________________

Phone (h)_____________________________

Emergency Contact #1

Emergency Contact #2

(to whom child may be released if parent/guardian is unavailable)

(to whom child may be released if parent/guardian is unavailable)

Name _________________________________________________________________

Name _________________________________________________________________

Address _______________________________________________________________

Address _______________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Relationship _______________________ Phone (c) ____________________________

Relationship _______________________ Phone (c) ____________________________

Phone (w) _________________________ Phone (h) ___________________________

Phone (w) _________________________ Phone (h) ___________________________

CHILD'S USUAL SOURCE OF MEDICAL CARE

Physician _________________________________________________________

Hospital ___________________________________________________________

Address ___________________________________________________________

Address ___________________________________________________________

________________________________________ Phone ___________________

________________________________________ Phone ___________________

Dentist ___________________________________________________________

Child’s Health Insurance _____________________________________________

Address ___________________________________________________________

Subscriber's Name ___________________________________________________

________________________________________ Phone ___________________

Specific Instructions of Special Conditions, Disabilities, Etc.

Allergies

Write none if none apply.

Write none if none apply.

As the parent/legal guardian, I give consent to SonShine Learning Center to administer to my child emergency first aid by the program staff. I understand that, if necessary, 911 will be

called and my child may be transported to receive emergency care. I understand that I will be responsible for all emergency transportation and any charges not covered by insurance.

I give consent for the emergency contact persons listed above to act on my behalf until I am available.

I agree to notify SonShine Learning Center if any of the above information changes.

Parent/Guardian #1

Date

Parent/Guardian #2

Date

Revised 1/15/15 NJM