Appendix ED-D2

CHILD CARE EMERGENCY CONTACT/PARENT/GUARDIAN CONSENT FORM

Child's Full Name: 	Birthdate:	 Child’s Address:  		 Classroom/Option:  		

Legal Guardian: 		Legal Guardian:  	

Relationship: 		Relationship:  	

Address: 		Address:  	

Phone Number: 		Phone Number:  	

Cell Phone: 		Cell Phone:  	

Email Address: 		Email Address:  	

Employer’s Name: 		Employer’s Name:  	

Employer’s Address: 		Employer’s Address:  	

Employer’s Phone: 		Employer’s Phone:  	

What is the best way to reach you while your child is in care? □ Work □ Cell-Call □ Text □ Email

Child Health Issues/Dietary Needs:  	

List current medications:  									 Does your child have any Disabilities? 	Yes 	No	IEP? 	Yes 	No	IFSP? 	Yes 	No
If, yes please list Disability:  	

If yes, list:  	

Does your child have any allergies? 	Yes 	No

Family Doctor: 		Phone:  	
Address:				 Medical Insurance Company: 		ID or Policy Number:  	

I, 	authorize Early Learning Connections, to 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 # During School	
Relationship To Child	

1.				

2.				

3.				

4.				

PARENT/GUARDIAN’S SIGNATURE IS REQUIRED FOR EACH
ITEM BELOW TO INDICATE CONSENT

Date:  	

Staff signature:  	

Date:  	

Parent/Guardian Signature:  	

I hereby authorize Early Learning Connections and its employees and staff to secure emergency care for my child as they deem necessary. I hereby release Early Learning Connections 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 six months.

1. Obtaining Emergency Medical Care	4. Admin. of Minor First Aid Procedures	
2. Walks and Trips	5. Swimming - NA	
3. Transportation by the Facility	6. Wading - NA	

Updates- Date: _____  Notes: _________________  Parent/Guardian Authorization: __________________
Periodic Review 		 	
Signature of Parent or Guardian (to be signed at 6 month review)	Date