Home Childcare Emergency Contact Permission Form
Child Information
Child's Full Name
Date of Birth
Home Address
Parent/Guardian Information
Parent/Guardian Name
Phone Number
Email Address
Emergency Contact (Other than Parent/Guardian)
Contact Name
Phone Number
Relationship to Child
Medical Information
Doctor's Name
Doctor's Phone Number
Known Allergies/Medical Conditions
Medications
Permissions
I give permission for emergency medical treatment.
I authorize transport by emergency vehicle if necessary.
I give permission to contact the emergency contact listed above.
Signature
Date