Learning Together Preschool
Learn ~ Grow ~ Thrive
Emergency Information
IMPORTANT: PLEASE FILL IN ALL INFORMATION INCLUDING ADDRESSES
THIS PAGE WILL BE PLACED IN OUR FILE AS WELL AS OUR EMERGENCY BACKPACKS SO WE CAN REACH YOU OR YOUR AUTHORIZED CONTACTS IN CASE OF AN EMERGENCY.
We also need this to verify the identity of the person picking up your child.
Name of child_______________________________________Birthdate:_________________
Does your child have allergies or medical conditions: YES, NO (If yes, please specify and describe any reactions)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
PARENT/GUARDIAN 1:___________________________________________________EMAIL:__________________
WORK#:_______________________ HOME#____________________ CELL#:_____________________
PARENT/GUARDIAN 2:___________________________________________________EMAIL___________________
WORK#:_______________________ HOME#____________________ CELL#:_____________________
Persons to be called in case of an emergency:
(This person should know your whereabouts. Give local contacts please)
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
In case of emergency person(s) authorized to pick up child from the preschool:
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
Hospital preference:_______________________________________________________________________________________________
Child’s Physician:_________________________________________Phone:______________________Date of last visit:________________
Address:_________________________________________________________________________________________________________
Child’s Dentist:______________________________________Phone:_______________
Address:_________________________________________________________________________________________________________
Insurance information (name of company, policy number and contact info):
________________________________________________________________________________________________________________
MEDICAL RELEASE
I HEARBY GRANT PERMISSION FOR LEARNING TOGETHER PRESCHOOL STAFF TO TAKE WHATEVER STEPS MAY BE NECESSARY TO OBTAIN MEDICAL TREATMENT IF WARRANTED, CONSENT TO MEDICAL OR SURGICAL TREATMENT BY ANY LICENSED PHYSICIAN AND/OR HOSPITAL, AND FURTHER CONSENT TO ADMINISTRATION OF NECESSARY ANESTHETICS, MEDICAL TREATMENTS, TESTS, TRANSFUSIONS, INJECTIONS, OR DRUGS AND PERFORMING OF WHATEVER OPERATIONS MAY BE DEEMED NECESSARY OR ADVISABLE IN THE EVENT OF AN EMERGENCY.
CHILD’S NAME_________________________________________________________
PARENT LEGAL SIGNATURE_____________________________________________
Please note: All attempts will be made to contact parent or legal guardian prior to medical treatment of any kind if possible without endangering the life or medical condition of your child.
DRUG ALLERGIES: ________________________________________________________________________________________
MEDICAL CONDITIONS_____________________________________________________________________________________
NAME OF ANY MEDICATIONS REGULARLY TAKEN_____________________________________________________________
DOCTOR: _______________________________ DOCTOR’S PHONE #:_____________________
THIS PAGE WILL BE PLACED IN OUR FILE AS WELL AS OUR EMERGENCY BACKPACKS SO WE CAN REACH YOU OR YOUR AUTHORIZED CONTACTS IN CASE OF AN EMERGENCY.
We also need this to verify the identity of the person picking up your child.
Name of child_______________________________________Birthdate:_________________
Does your child have allergies or medical conditions: YES, NO (If yes, please specify and describe any reactions)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
PARENT/GUARDIAN 1:___________________________________________________EMAIL:__________________
WORK#:_______________________ HOME#____________________ CELL#:_____________________
PARENT/GUARDIAN 2:___________________________________________________EMAIL___________________
WORK#:_______________________ HOME#____________________ CELL#:_____________________
Persons to be called in case of an emergency:
(This person should know your whereabouts. Give local contacts please)
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
In case of emergency person(s) authorized to pick up child from the preschool:
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
Name:________________________________ Phone:___________________ Relationship to child:______________________________
Address:_________________________________________________________________________________________________________
Hospital preference:_______________________________________________________________________________________________
Child’s Physician:_________________________________________Phone:______________________Date of last visit:________________
Address:_________________________________________________________________________________________________________
Child’s Dentist:______________________________________Phone:_______________
Address:_________________________________________________________________________________________________________
Insurance information (name of company, policy number and contact info):
________________________________________________________________________________________________________________
MEDICAL RELEASE
I HEARBY GRANT PERMISSION FOR LEARNING TOGETHER PRESCHOOL STAFF TO TAKE WHATEVER STEPS MAY BE NECESSARY TO OBTAIN MEDICAL TREATMENT IF WARRANTED, CONSENT TO MEDICAL OR SURGICAL TREATMENT BY ANY LICENSED PHYSICIAN AND/OR HOSPITAL, AND FURTHER CONSENT TO ADMINISTRATION OF NECESSARY ANESTHETICS, MEDICAL TREATMENTS, TESTS, TRANSFUSIONS, INJECTIONS, OR DRUGS AND PERFORMING OF WHATEVER OPERATIONS MAY BE DEEMED NECESSARY OR ADVISABLE IN THE EVENT OF AN EMERGENCY.
CHILD’S NAME_________________________________________________________
PARENT LEGAL SIGNATURE_____________________________________________
Please note: All attempts will be made to contact parent or legal guardian prior to medical treatment of any kind if possible without endangering the life or medical condition of your child.
DRUG ALLERGIES: ________________________________________________________________________________________
MEDICAL CONDITIONS_____________________________________________________________________________________
NAME OF ANY MEDICATIONS REGULARLY TAKEN_____________________________________________________________
DOCTOR: _______________________________ DOCTOR’S PHONE #:_____________________