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Child Care
Emergency Consent Form

CHILD’S FIRST NAME(S):
CHILD’S SURNAME
DATE OF BIRTH
ADDRESS:
PARENT’S NAME: HOME PHONE:
CELL PHONE: WORK PHONE:
PARENT’S NAME: HOME PHONE:
CELL PHONE: WORK PHONE:
EMAIL:
EMERGENCY CONTACT: CELL PHONE: PHONE:
OUT OF TOWN CONTACT: PHONE:
CHILD’S DOCTOR: PHONE:
TETANUS SHOT DONE:
ALLERGIES / MEDICATIONS:
CHILD’S DENTIST: PHONE:
CARE CARD NUMBER:

CONSENT

  1. It is the policy of this facility to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Our procedure is to call for an ambulance.
  2. Please sign the consent below so that we can take the appropriate action on behalf of your child. Return the signed consent to the facility immediately. We will take this consent with us to the emergency centre.
  3. I hereby give consent for my child to be taken to the nearest emergency centre when I cannot be contacted.
  4. I hereby give consent for my child named above to receive medical treatment.
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