Child’s Name_________________________ Home Phone _______________________

Birth Date _______________ Home Address__________________________________

Weight ____________ Child’s Social Security # ____________________

Mother’s Name _____________________ Father’s Name _______________________

Employed At _______________________ Employed At _________________________

Business Phone ____________________ Business Phone ______________________

Insurance Company ________________________ Last Tetanus Shot ______________

Medications taken on a daily basis __________________________________________

Allergies ______________________________________________________________

Name of friends or relatives who can pick up child in case of emergency:

1. __________________________ Phone __________________or _______________
2. __________________________ Phone __________________or _______________

Names of people who cannot pick up child for any reason:

1. _________________________________________
2. _________________________________________

Physician/Dentist to be called in an emergency:

1. ___________________________ Phone _________________or_______________
2. ___________________________ Phone _________________or_______________

Hospital Preference ___________________________

I hereby grant permission for the director or supervisory staff person to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include:

1. Attempt to contact a parent or guardian.
2. Attempt to contact the child’s physician.
3. Attempt to contact you through any of the persons listed on the emergency information form you completed for us.
4. If we cannot contact you or your child’s physician, we will do any or all of the following: (a) Call another physician or paramedic, (b) call an ambulance, (c) have the child taken to an emergency hospital in the company of a staff member.
5. The child's family will pay any expenses under 4 above.