Our home address:
__________________________________________________________
Our home phone number:
_________________________
Where I can be reached:
Location: _______________________________ Phone Number:___________________
Our cellular phone numbers: ________________________ ______________________
I expect to be home at this time:__________________________
Who to call if you can�t reach me:
Name: __________________________________ Phone Number: _________________
Name: __________________________________ Phone Number: _________________
Out of Area Contact:
Name: __________________________________ Phone Number: _________________
What child can eat and when: ______________________________________________________________________
What [child] cannot eat:
______________________________________________________________________
What [child] can watch on TV (favorite shows and channels):
______________________________________________________________________
What [child] cannot watch on TV:
______________________________________________________________________
Things [child] likes to do (favorite activities such as art projects, books,games etc) :
______________________________________________________________________
Things not allowed:
______________________________________________________________________
Bedtime (time and routine):
______________________________________________________________________
Common discipline problems:
______________________________________________________________________
Consequences for misbehavior:
______________________________________________________________________
In Case of Emergency:
Our closest major intersection is:
______________________________________________________________________
Our closest neighbor you can contact in an emergency:
Name:______________________________ Phone number: _____________________
Address: ______________________________________________________________________
In case of evacuation, meet at this place:
______________________________________________________________________
Pediatrician's Name, Address, and Phone Number
______________________________________________________________________
Closest Hospital and Directions
______________________________________________________________________ ______________________________________________________________________
Hospital ER Phone Number: __________________________
Insurance Information
Provider: _______________________ Group ID# _______________________
Insured�s Name and ID# __________________________ Policy ID# ______________
Emergency Treatment Release
Child's Name: _____________________________ Birthdate: / /
Any licensed physician, dentist or hospital may give necessary emergency medical service to my child/ren _____________________________________________________ at the request of the person bearing this consent form.
____________________________________________ _________________
Signature of Parent or Legal Guardian Dates of Release
All caregivers must have a copy of their current drivers license with this form.
