Child Care Emergency Form

Gather medical details, emergency contacts, and authorizations in one place so a child care center can respond quickly if something happens.

Use this template

Name of Child

Nombre

Apellido

Date of Birth

Name of Parent/Guardian

Nombre

Apellido

Phone Number

Email

Home Address

Dirección

Ciudad

Estado / Provincia

Código postal

Is the parent working?

Yes No

Work Place

Work Phone Number

Work Address

Dirección

Ciudad

Estado / Provincia

Código postal

Section

If the child has any health conditions and/or allergies please explain

Do you want to add some medical documents?

Max 10 MB per file

Name of Physician/Pediatrician

Nombre

Apellido

Phone Number

Name of Dentist/Orthodontist:

Nombre

Apellido

Phone Number

Preferred Medical Facility

Insurance Company

Policy Number

Section

I, the parent/guardian of the child stated above, authorize the childcare to get the rights of the following stuations

I authorize

Date

Signature

Sign here

Child Care Emergency Form

Section

Section

Section

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