Emergency Consent Card

EMERGENCY CONSENT CARD

Name of Facility: Life Stars Family Childcare

Child’s Name:(Required)

First Last

Date(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Parent’s Name:(Required)

First Last

Child lives with:(Required)

Work Phone:(Required)

Home Phone:(Required)

Child’s Doctor:(Required)

First Last

Phone:(Required)

Allergies

Medications

Date Effective:(Required)

Care Card number:(Required)

Consent Form

It is the policy of this centre to notify a parent when a child is ill or needs attention. In the event we cannot contact you and we need to get immediate help for your child, we require a signed consent to do so. 1. I give consent for my child to be taken to the nearest emergency medical centre when I cannot be contacted. 2. I give consent for my child to receive medical treatment.

Name of Parent/ Guardian:(Required)

First Last

Date(Required)