Case/Concord Child Development Center

CASE/CONCORD CHILD DEVELOPMENT CENTER

EMERGENCY CARD

CHILD’S NAME ______DOB ______GENDER ______

PARENT’S NAME ______

HOME ADDRESS ______

MAILING ADDRESS ______

HOME PHONE ______CELL ______

MOTHER’S EMPLOYER ______PHONE ______

FATHER’S EMPLOYER ______PHONE ______

PERSONS OTHER THAN PARENTS WHO MAY BE CALLED IN CASE OF AN EMERGENCY

NAME ______RELATION ______PHONE ______

PERSONS OTHER THAN PARENTS AUTHORIZED TO PICK UP YOUR CHILD FROM THE CENTER. ( I.D. REQUIRED)

NAME/ADDRESS ______

RELATION ______PHONE ______

NAME/ADDRESS ______

RELATION ______PHONE ______

NAME/ADDRESS ______

RELATION ______PHONE ______

IF SCHOOL AGE, WHAT SCHOOL DO THEY ATTEND ______

PHONE ______TEACHER’S NAME ______

CASE/CONCORD CHILD DEVELOPMENT CENTER

EMERGENCY CARD

CHILD’S NAME ______DOB ______GENDER ______

PARENT’S NAME ______

HOME ADDRESS ______

MAILING ADDRESS ______

HOME PHONE ______CELL ______

MOTHER’S EMPLOYER ______PHONE ______

FATHER’S EMPLOYER ______PHONE ______

PERSONS OTHER THAN PARENTS WHO MAY BE CALLED IN CASE OF AN EMERGENCY

NAME ______RELATION ______PHONE ______

PERSONS OTHER THAN PARENTS AUTHORIZED TO PICK UP YOUR CHILD FROM THE CENTER. ( I.D. REQUIRED)

NAME/ADDRESS ______

RELATION ______PHONE ______

NAME/ADDRESS ______

RELATION ______PHONE ______

NAME/ADDRESS ______

RELATION ______PHONE ______

IF SCHOOL AGE, WHAT SCHOOL DO THEY ATTEND ______

PHONE ______TEACHER’S NAME ______

PHYSICIAN’S NAME ______PHONE ______

ADDRESS ______

DENTIST’S NAME ______PHONE ______

ADDRESS ______

HOSPITAL PREFERRED ______

HEALTH INSURANCE COMPANY ______PHONE ______

ADDRESS ______POLICY # ______

ONGOING MEDICATIONS ______

ALLERGIES ______

I GIVE PERMISSION TO ADMINISTER EMERGENCY MEDICAL TREATMENT TO MY CHILD AND TO TRANSPORT TO THE NEAREST MEDICAL FACILITY. YES NO (CIRCLE ONE)

I GIVE PERMISSION FOR MY CHILD TO BE VIDEO AND/OR AUDIO TAPED AND/OR PHOTOGRAPHED. YES NO

PARENT’S SIGNATUREDATE

PLEASE HAVE THIS NOTORIZED BELOW

PHYSICIAN’S NAME ______PHONE ______

ADDRESS ______

DENTIST’S NAME ______PHONE ______

ADDRESS ______

HOSPITAL PREFERRED ______

HEALTH INSURANCE COMPANY ______PHONE ______

ADDRESS ______POLICY # ______

ONGOING MEDICATIONS ______

ALLERGIES ______

I GIVE PERMISSION TO ADMINISTER EMERGENCY MEDICAL TREATMENT TO MY CHILD AND TO TRANSPORT TO THE NEAREST MEDICAL FACILITY. YES NO (CIRCLE ONE)

I GIVE PERMISSION FOR MY CHILD TO BE VIDEO AND/OR AUDIO TAPED AND/OR PHOTOGRAPHED. YES NO

PARENT’S SIGNATUREDATE

PLEASE HAVE THIS NOTORIZED BELOW