Elizabeth's Home Daycare

CHILD/REN                            

(1) Last Name:

First Name:

Middle Name:

Nickname:

Address

Home Phone:

Hair Colour:

Eye Colour:

Birth Date:

Start Date:

(2) Last Name:

First Name:

Middle Name:

Nickname:

Address

Home Phone:

Hair Colour:

Eye Colour:

Birth Date:

Start Date:

NAMES OF SIBLINGS & BIRTH DATES:  

PARENTS OR GUARDIANS

(1) Last Name:

First Name:

Relationship to Child:

Address:

City:

Postal Code:

Home Phone:

Work Phone:

Cell Phone:

Other Phone:

Employer:

(2) Last Name:

First Name:

Relationship to Child:

Address:

City:

Postal Code:

Home Phone:

Work Phone:

Cell Phone:

Other Phone:

Employer:

OTHER EMERGENCY CONTACT

Name:

Relationship to Child:

Home Phone:

Work Phone:

Cell Phone:

Other Phone:

AUTHORIZATION FOR PICKUP

Your child will only be released to an authorized person listed on this form (parent/guardian and/or emergency contact). In case of an emergency or an unforeseen circumstance, please indicate the name, address and phone number of any other person/s who you authorize to pickup your child on your behalf. 

 Name                                          Phone                                        Relationship to Child

A parent/guardian's verbal authorization for pickup must be received before your child will be released to anyone not listed here. If not received, and I cannot notify you by phone, the child will not be released.

MEDICAL INFORMATION

Child’s Doctor:

Office Phone:

Address:

City:

Postal Code:

Health Card #

*please also include copy of current immunization record

Allergies:

Medical Problems: 

Medication:

EMERGENCY CONSENT:

It is my policy to notify a parent when a child is ill or needs medical attention.  Occasionally, I cannot contact a parent and I need to get immediate help for the child. My procedure is to take the child to the nearest emergency service.

Please sign below so that I can take appropriate action on behalf of your child.

I HEREBY GIVE MY/OUR CONSENT FOR MY/OUR CHILD ____________________________  WHEN  ILL/INJURED, TO BE TAKEN TO THE NEAREST EMERGENCY CENTER BY ELIZABETH RUTH WHEN I/WE CANNOT BE CONTACTED.  I CONSENT TO AN AMBULANCE BEING CALLED TO TRANSPORT THE CHILD, IF NECESSARY.  I FURTHER AGREE TO PAY ALL COSTS INCURRED FOR TRANSPORT.
 

       Parent/Guardian Signature                             Parent/Guardian Signature

          Date:                                                                   Date: