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ER Form Revised April 2014

This emergency form must be completed before a child can attend class with an updated immunization record. It requests contact information for parents and two emergency contacts if parents are unavailable. It also asks for medical insurance information, health care providers, any medical needs or allergies, and provides consent for emergency medical care and transportation if necessary. The parent must sign agreeing to these terms.

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85 views1 page

ER Form Revised April 2014

This emergency form must be completed before a child can attend class with an updated immunization record. It requests contact information for parents and two emergency contacts if parents are unavailable. It also asks for medical insurance information, health care providers, any medical needs or allergies, and provides consent for emergency medical care and transportation if necessary. The parent must sign agreeing to these terms.

Uploaded by

gopikrish04
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Emergency Form

State licensing requirement: This formand an updated immunization record must be completed and submitted to our program
before your child can attend the rst day of class. All RED items MUST be completed.
In event of an injury requiring medical attention, staff will attemp to contact the parent(s)..
Mothers phone: (Cell) Fathers phone: (Cell)
(W) (H) (W) (H)

List two contacts if parents are unavailable for child emergency or if attending parent needs medical attention.
Contact 1: Contact 2:
Address: Address:
City: Zip: City: Zip:
Phone: (H) (C) Phone: (H) (C)
Relationship: Relationship:
Who, if anyone, is authorized to provide transportation to and fromschool (in addition to parents/guardians)?
Name: Name:
Phone: Phone:
Is there anyone legally NOT allowed to transport your child?
Name: ___________________________________________________ Relationship: ____________________________________

Family Physician: Dentist:
Address: Address:
City Zip: City Zip:
Phone: Phone:
Health insurance provider: Dental insurance provider:
Account number: Account number:
ID number: ID number:
Check here if you choose not to provide health insuranceinformation. Check here if you choose not to provide dental insurance information.
Specic instruction regarding emergency care? Hospital preference?

Does your child have dietary or medical needs (including allergies) Yes ___ No ___ If yes, please explain.

Phone: 763-745-5290
Fax: 763-745-5291
Childs name: Birth date:
Parent/Guardian name(s):
Mothers home address:
City: State: Zip:
Fathers home address (if different)
City: State: Zip:
Who does this child live with?
I understand that in some emergency situations the Center will need to contact the emergency medical service before the parent, childs
physician, and/or other adult acting on the parents behalf. In the event of a medical emergency, I understand that my child will be trans-
ported to the nearest hospital, if the local emergency unit determines this is necessary. The child will be transported at the expense of the
parent. I hereby grant permission to the staff of Wayzata Family Learning Center to take whatever emergency measures are judged neces-
sary for the care and protection of my child, ___________________________________________________ while under the supervision of
the Center.

(Parent/Guardian Signature) (Date)
(Childs Name)
Date of last tetanus (DPT) shot:

I authorize Wayzata Family Learning Center to obtain medical information from my child's health care provider when necessary.

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