Child’s Care and Emergency Information Child's Name Parent / Guardian Name First Name Last Name Parent Signature & Date Type Your Name & Date Child's Date of Birth MM DD YYYY Home Phone Number (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Special Health Conditions (if any) Parent 1's location when child is in care Employer, School, etc. Hours of Employment Employer's Phone Number (###) ### #### Employer's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent 2's location while child is in care Employer, school, etc. for the Other Parent Hours of Employment Employer's Phone Number Employer's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Person Other Than Parent to be Notified in and Emergency Situation When Parent is NOT Available Please provide their name, phone number, and address. Name of persons other than the parent to which the child may be released. Please provide their names below (up to 4 people). EMERGENCY TREATMENT AND TRANSPORTATION I hereby give permission to Chosen Childcarelicensed by the Division of Child Development to secureemergency medical, dental, and/or emergency surgical treatment and to provide emergency transportation for the above named minor child while in care. Non-emergency medical treatment or elective surgery is not included in this authorization. Type in your NAME & DATE below Name of Child's Physician or Health Clinic Office Hours Physician's Phone Number (###) ### #### Physician's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Hospital Preferred for Emergency Treatment Health Insurance Policy Name & Number Name of Child's Dentist Office Hours Dentist's Phone (###) ### #### Dentist's Address Address 1 Address 2 City State/Province Zip/Postal Code Country FIELD TRIPS & OUTSIDE PLAY I hereby give permission to Chosen Childcare for my child to participate in a walking trip or to be transported in a vehicle for a field trip. I understand that provision will be made for daily rest and outside play. Please type your NAME & DATE below. Thank you!
