Emergency Contact And Parental Consent

THIS FORM MUST BE TAKEN WITH THE CHILD WHEN EMERGENCY MEDICAL CARE IS NEEDED.

Persons authorized to pick up child:

WRITTEN CONSENT IS GIVEN FOR:

EMERGENCY MEDICAL CARE
Medication Authorization form and Medication Administration Log Must be completed
OTC Medication Authorization Form and Medication Administration Log must be completed

IF YOUR CHILD IS TRANSPORTED BY THE FACILITY, ARE THERE ANY INSTRUCTIONS FOR SPECIAL CARE FOR THE CHILD (I.E. MOTION SICKNESS, SEIZURES, ETC.) DURING TRANSPORTATION?

HEALTH HISTORY

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