Emergency Contact & Consent Form Child's Name(Required) First Last Birthdate(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City ZIP / Postal Code Parent/Guardian #1 Name(Required) First Last Home Phone(Required)Cell PhoneWork PhoneEMERGENCY CONTACTSName #1(Required) First Last Relationship(Required) Home Phone(Required)Cell PhoneWork PhoneName #2(Required) First Last Relationship(Required) Home Phone(Required)Cell PhoneWork PhoneCHILD'S PREFERRED SOURCES OF MEDICAL CAREPhysician's Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneDentist's Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneHospital's Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneCHILD'S HEALTH INSURANCEInsurance Plan ID# Subscriber Name (on insurance card) First Last SPECIAL CONDITIONS, DISABILITIES, ALLERGIES OR MEDICAL EMERGENCY INFORMATIONDescribe: PARENT/GUARDIAN CONSENT AND AGREEMENT FOR EMERGENCIES As parent/gaurdian, I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive emergency care. I will be responsible for all charges not covered by insurance. I consent for the emergency contact person listed above to act on my behalf until I am available. I agree to review and update this whenever a change occurs and at least every 6 months. Parent/Guardian Signature(Required)Date MM slash DD slash YYYY Parent/Guardian Signature(Required)Date MM slash DD slash YYYY Enrollment Forms & Information Program Offerings 2023-24 School Calendar 2023-24 Little Stars Preschool Packet Parent Information Sheet Little Stars Enrollment Form All About Me! Contact & Consent Form
