Emergency Contact Parental Consent Form
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1EMERGENCY CONTACT PARENTAL CONSENT FORM
55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182
CHILD’S NAME
BIRTH DATE
ADDRESS
MOTHER’S NAME/LEGAL GUARDIAN
HOME TELEPHONE NUMBER
E-MAIL ADDRESS
MOBILE TELEPHONE NUMBER
ADDRESS
BUSINESS NAME
BUSINESS TELEPHONE NUMBER
ADDRESS
FATHER’S NAME/LEGAL GUARDIAN
HOME TELEPHONE NUMBER
E-MAIL ADDRESS
MOBILE TELEPHONE NUMBER
ADDRESS
BUSINESS NAME
BUSINESS TELEPHONE NUMBER
ADDRESS
EMERGENCY CONTACT PERSON(S)
NAME
TELEPHONE NUMBER WHEN CHILD IS IN CARE
PERSON(S) TO WHOM CHILD MAY BE RELEASED
NAME
ADDRESS
TELEPHONE NUMBER WHEN CHILD IS IN CARE
NAME OF CHILD’S PHYSICIAN/MEDICAL CARE PROVIDER
TELEPHONE NUMBER
ADDRESS
ALLERGIES (INCLUDING MEDICATION REACTIONS)
SPECIAL DISABILITIES (IF ANY)
MEDICATION, SPECIAL CONDITIONS
MEDICAL OR DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION
ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD
POLICY NUMBER (REQUIRED)
HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS
PARENTS SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT
ADMIN. OF MINOR FIRST - AID PROCEDURES
OBTAINING EMERGENCY MEDICAL CARE
SWIMMING
WALKS AND TRIPS
WADING
TRANSPORTATION BY THE FACILITY
PERIODIC REVIEW
DATE
SIGNATURE OF PARENT OR GUARDIAN
DATE
SIGNATURE OF PARENT OR GUARDIAN
03891A
ORIGINAL
CY 867 - 1/93
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