EARLY LEARNING CONNECTIONS	Appendix ED-D5
139 Rieger Road, Butler, PA 16001

PREGNANT MOTHER RELEASE AND EMERGENCY TREATMENT FORM

Full Name: _____________________________________________________Birth Date:  _____________	 Due Date: ________________________
Address: ____________________________________________________________________________________ Email:  __________________________
  Primary Phone Number: ______________________I agree to receive text messages to notify me of Delays, Cancellations and Events _______Yes______No
  Pregnant Mothers Primary Doctor:  ________________________________________ Phone:  __________________________________________________

  Medical Insurance Company:  	          ID or Policy Number:  	___________________________  _____________
  Any allergies ____YES______No     If yes, list:  	 Health Issues/Current medications: ______________________________________

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 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 	
Relationship To Mother	             Additional	
•		•		•		•		Information	

1.					

2.					

3.					
I hereby authorize Early Learning Connections, Inc. and its employees and staff to secure emergency care for my child as they deem necessary. I hereby release Early Learning Connections, Inc. and its employees from any and all liability and claims pertaining to my child while in its care, custody and control. This Authorization and Release shall continue in effect until revoked in writing or for one year.

Pregnant Mothers Signature: 		Date:	

Staff Signature: 		Date:		
•			
Updates:
Date: 	Notes: 	Parent/Guardian Authorization: