Emergency Contact & Parental Consent Form

Parent/Legal Guardian #1 Contact Information
Parent/Legal Guardian #2 Contact Information

Emergency Contacts

Emergency Contacts (list at least 1 and up to 3)
Daytime phone
Person/people to whom child may be released (list at least 1 and up to 3)

Health Care Overview

Child's Physician/Medical Care Provider
Special Disabilities (if any)
Allergies (if any); include medication reaction/s
Medical or Dietary Information necessary in an emergency situation
Additional information about child's special needs (if any)
Child's Health Insurance Provider or medical-assistance benefits
Child's health insurance/medical benefits policy number
Sign to consent to obtaining medical care during an emergency
Sign to consent to administering minor first-aid procedures
Sign to consent to PCC walks and trips
Sign to consent to PCC-provided transportation during the day 
Signature of Parent or Guardian #1
Signature of Parent or Guardian #1
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