1 (fill out as information changes)

SERIOUS KNOWN ALLERGIES                                                                                             DATE

 

EMERGENCY CONTACT INFORMATION

Full name of Child:                                                                                             M or F                    Birth date             

 

Full name of Child:                                                                                             M or F                    Birth date             

 

 

Full name of Parent/s or Guardian/s:  Father                                                 Mother

 

 

Address:

 

Home Phone:         

 

Mothers Cell Phone:                                                     Is it ok to text?                               Mothers Work Phone:

 

Fathers Cell Phone                                                    Is it ok to text?                               Fathers Work Phone:

 

Mothers Email Address:                                                                                                       Do you use your email daily?  

               

Fathers Email Address:                                                                                                    Do you use your email daily?

 

Fathers Place of Employment (Name, Address, Phone Number):

 

 

Mothers Place of Employment (Name, Address, Phone Number):

 

Two names, phone numbers and address of nearest relatives or persons to contact in case of an emergency when you are not available  allowed to pick child up:

  1.  

  1.  

People NOT allowed to pick child up.

 

Please describe child’s health history, last date of physical exam, allergies, special dietary requirements medications and other special need to be aware of:                   

 

Print & Signature of Mother/Guardian                     Date                       Print & Signature of Father/Guardian                       Date      

 

 

 

 

Doctors - Names, phone numbers and address of Doctor / Clinic               Date of last physical:

 

 

Dentist - Names, phone numbers and address of Doctor / Clinic               Date of last exam: write NONE if no appointment

 

MEDICAL CONSENT FORM: In the event of a dental or medical emergency, it will be necessary to have the following information: I ________________________________________   parent/guardian of  __________________________________                                                                                             hereby give permission to PATTI JULAGAY my Family Childcare Provider, to secure and authorize such emergency medical care / dental care / and/or transportation to emergency facility for the above-named child, that they may require while under the supervision of said Childcare Provider. I further authorize said childcare provider to administer emergency care/treatment as required, until medical assistance is available. I also agree to pay all costs and fees related to any emergency medical care and/or treatment for said child as secured or authorized under this consent. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment.

MEDICAL INSURANCE INFORMATION: (provide a copy of Insurance Card)

Name of Company Phone Number                                                     Name of Member                             Policy Number Group Number