Emergency Contact Form
Child's Full Name (First, Middle, Last) *
Your answer
Birthdate
MM
/
DD
/
YYYY
Email
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Mother/Guardian Name (First, Middle, Last) *
Your answer
Address *
Your answer
Company Name
Your answer
Company Address
Your answer
Hours
Your answer
Phone & Ext.
Your answer
Pager
Your answer
Father/Guardian Name (First, Middle, Last) *
Your answer
Address *
Your answer
Company Name
Your answer
Company Address
Your answer
Hours
Your answer
Phone & Ext.
Your answer
Pager
Your answer
EMERGENCY CONTACTS - In case child listed above becomes ill or is injured and I (Parent/Guardian) cannot be contacted, CTMH has my permission to contact and release my child to the custody of one of the emergency contacts listed below:
First Contact:
Name *
Your answer
Relationship *
Your answer
Phone *
Your answer
Address *
Your answer
Second Contact:
Name *
Your answer
Relationship *
Your answer
Phone *
Your answer
Address *
Your answer
Third Contact:
Name
Your answer
Relationship
Your answer
Phone
Your answer
Address
Your answer
MEDICAL INFORMATION
Family Physician's Name *
Your answer
Clinic Name *
Your answer
Clinic Address *
Your answer
Child's Health Card #
Your answer
Hospital you prefer: *
Your answer
Are there any known illness, injuries allergies, health or medical conditions that the Provider should be made aware of? *
If yes, please describe.
Your answer
Specific Instructions of Parent/Guardian: (i.e. allergies, ongoing medication, restrictions for treatment, etc.)
Your answer
PARENTAL CONSENT: The information on this form will be used in emergency situations. School Personnel, ctmh employees, health service staff, bus aides and drivers will have this information in the event of an emergency. If at any time, due to such circumstances as a sudden illness, or emergency and medical treatment is required, this card will be given to the necessary Personnel including a private physician, hospital, and aesthetic, if necessary, or hospital. I give permission to close to my heart to make whatever emergency measures as judge necessary for the care and protection of my child while under the supervision of the program. In case of medical emergency, I understand that my child will be transported to St Paul Children's Hospital, if the local emergency source (police/rescue squad) deems it necessary. In the event of accidental ingestion, I understand that Close to My Heart Will contact the Poison Control Center. I give permission for the staff to administer Syrup of Ipecac to my child if directed by the Poison Control Center. By typing my name below, I hereby authorize the program to act on my behalf in case of an emergency.
Full Name *
Your answer
I give my consent to Close to My Heart staff to act on my behalf in case of an emergency with my child. *
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