Emergency Authorization Form - Bilingual Child Care & Education Center, Inc.

Emergency Contact Information

Child's Name*

First Middle Last

Birth Date*

Parent/Guardian 1*

First Last

Parent/Guardian 1 - Daytime Phone*

Parent/Guardian - 2

First Last

Parent/Guardian 2 - Daytime Phone

Emergency Contact 1*

First Last

Emergency Contact 1 - Address*

Street Address City State ZIP Code

Emergency Contact 1 - Phone Number*

Emergency Contact 2*

First Last

Emergency Contact 2 - Address*

Street Address City State ZIP Code

Emergency Contact 2 - Phone Number*

Medical Provider Information

Child's Medical Provider*

Medical Provider's Phone Number*

Medical Provider's Address*

Street Address City State ZIP Code

Child's Dental Provider*

Dental Provider's Phone Number*

Dental Provider's Address*

Street Address City State ZIP Code

Medical Insurance Company*

Last DPT Vaccination*

Child's Current Weight*

Allergies or other significant medical information including medications.

If none, leave blank.

Parent/Guardian Consent

Parent/Guardian Consent*

I give permission to Bilingual Child Care & Education Center to take whatever emergency measures are judged necessary for the care and protection of my child while under the supervision of their Center. In case of a medical emergency, I understand that my child will be transported to an appropriate medical facility by the local emergency resource (Police, Rescue Squad) deems it necessary. I understand that in some medical situations it may be necessary to contact the emergency resource before the parent.

I agree to the the Emergency Authorization Form

CAPTCHA

What is 3+4?*