EARLY LEARNING CONNECTIONS	Appendix ED-D1
139 Rieger Road, Butler, PA 16001

Child's Full Name: 	Birth Date:  	 Child’s Address: 	Classroom/Option:  	
Primary Phone: 	Email:  	

CHILD RELEASE AND EMERGENCY TREATMENT FORM

Legal Guardian: 	Legal Guardian:  	 Relationship: 	Relationship:  	
Address: 		Address:		 (if different than Child’s)		(if different than Child’s)
Home Number: 	Home Number:  	

Cell Number: 	Cell Number:  	

Employer’s Name: 	Employer’s name:  	

Employer’s Address: 	Employer’s address:  	

Employer’s Phone: 	Employer’s phone:  	

Can you accept calls at work? 	Yes 	No	Can you accept calls at work? 	Yes 	No

Child Health Issues:  	

List current medications:  	

ID or Policy Number:  	
If yes, list:  	

Medical Insurance Company:  	
Does your child have any allergies?	 	Yes	 	No

Phone:  	

Child’s Doctor:  	

Cell Phone:  	

Additional Contact Person:  	

I agree to receive text messages to notify me of Delays, Cancellations and Events	 	Yes	 	No

I, 	, authorize Early Learning Connections, Inc. to contact the following people in case of an emergency regarding me and/or my child, or release my child 		to the following adults:
•	All adults listed below must be at least 16 years of age.
•	The adults must carry personal identification, preferably a photo ID. If not a photo ID, two other forms of ID.

Name	
Address	
Phone Number During School	Relationship To Child	
•		•		•		•		

1.				

2.				

3.				

4.				

5.				

6.				

7.				

   Staff Signature: ________________________________________________________________                          Date: __________________________

   Parent/Guardian Signature: _______________________________________________________                          Date: __________________________

Updates:
Date: 	Notes: 	Parent/Guardian Authorization:  	

Date: 	Notes: 	Parent/Guardian Authorization:  	

Date: 	Notes: 	Parent/Guardian Authorization:  	

 ADD/Forms/Intake Packet Forms/Child Release and Emergency Treatment Form