EMERGENCY CARD
INFORMATION
Child's Name: ______________________________ Date of Birth: ____________________________
Child's Home Address:
_______________________________________ Phone:_____________________
INSTRUCTIONS TO REACH PARENT/GUARDIAN
Name:_____________________ Address_________________________,
Phone_______________
Name:_____________________ Address_________________________,
Phone_______________
PEDIATRICIAN
OR SOURCE OF HEALTH CARE . (Doctor's
Name, Address, Phone#)
EMERGENCY CONTACT PERSON(S)
1. Name, Address, Phone #)
2. (Name, Address, Phone #)
MEDICAL EMERGENCY TREATMENT
I hereby give Wareham Child
Care permission to administer basic first aid and/or CPR to my child,
___________________________, and/or take
my child , to a hospital for medical treatment
when I cannot be reached or when delay would be dangerous to my child's health.
___________________________________________________________________________________
(Parent Signature) (Date)
INSURANCE INFORMATION (OPTIONAL)
Company Name:___________________________
Policy #_____________________________________________________________________
Participating Hospital:__________________________________________________________