Emergency Contact and Authorization to pick up
Please list 3 local individuals to contact in the event of an emergency
School Age Children
My child attends the following school:
Authorization for Emergency Medical Attention
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge
to take my child to:
My child will normally be in attendance the follow days and times:
List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and
hospitalizations during that past 12 months, and medication prescribed for long-term continuous use, and any other
information which caregivers should be aware of:
From time to time our facility may take photographs for educational use. I give consent for the facility to take
photographs of my child.
I understand that the staff at this facility are prohibited in participating in outside employment with parents.
I understand that the staff at this facility are prohibited in participating in social networking activities with parents and
children enrolled at the facility. (Such as Facebook, MySpace, and Twitter)