EMERGENCY FORM

Provider's Name: _____________________________________________________

Child's First & Last Name: ___________________________

Birth date:___________________________________________
Mother's First & Last Name (or Guardian): ___________________________________________
Address: ______________________________ Phone: (    ) ______________________
Company Name & Address: _______________________________________________________
Hours: _____________________Phone & ext. ___________________________________
Cellular phone: ______________________

Father's First and Last Name (or Guardian): _________________________________________
Address: ________________________________ Phone: (   ) ____________________
Company Name & Address: _______________________________________________________
Hours: ____________________ Phone & ext. ___________________________________
Cellular phone: ______________________

IF ABOVE PERSONS ARE NOT AVAILABLE: Names and addresses of persons to be contacted and to whom the child may be released (must give three contacts):
Name: ____________________________ Relationship: ____________________________
Address: _______________________________Phone: ____________________________
Name: ____________________________Relationship: ____________________________
Address: ______________________________Phone: ____________________________
Name: ____________________________Relationship: ____________________________
Address: _____________________________
_ Phone: ____________________________

Family Physician's Name: ____________________ Phone:_____________________________
Address: ______________________________________________________________________

Child's HEALTH CARD #
 _________________________________________________
Hospital you prefer: ______________________________________________
Are there any known allergies, health or medical conditions that the Provider should be made aware of? Circle YES or NO. If yes, please describe: __________________________________________________________________________________________________________________________________________________________________________________________

PARENT'S CONSENT: If, at any time, due to such circumstances as accident, sudden illness, or emergency, and medical treatment is required, this may be given, including anesthetic, if necessary, by a private physician or hospital.
SPECIFIC INSTRUCTIONS OF PARENT/ GUARDIAN (i.e. Allergies, ongoing medication, restrictions for treatment, etc.):________________________________________________________________________________________________________________________________________________________

 
 
___________________________                ___________

   Signature of Parent/Guardian                                  Date