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ECC Emergency Information

* Child's Name

Address

Date of Birth

Child's Preferred Nick Name

Gender identity your child identifies

Please list names/numbers in the order in which we should call should it be necessary to do so!

1. Parent/Guardian Name

Home phone number

Cell phone number

Work phone number

Email Address

Okay to Text

Yes- Text

No - Text

2. Parent/Guardian Name

Home phone number

Cell phone number

Work phone number

Emergency Contacts (who can pick up your child if parent or guardian is unavailable):

Name #1

Relationship

Address

Cell phone number

Name #2

Relationship

Address

Cell phone number

Additional Pick-up Information

Do you authorize anyone not listed above to pick up your child?

If yes, please list name(s) and phone number(s)

Child's Usual Source of Medical Care

Name

Address

Telephone

Child's Usual Source of Dental Care

Name

Address

Telephone

Child's Health Insurance

Name of Insurance Plan

ID #

Subscriber's Name (on insurance card)

Special Requirements

None

Early Intervention/ Special Education

Occupational Therapy

Speech/ Language

Physical Therapy

Allergies

Other

* Special Conditions, disabilities, allergies, or medical information for emergency situations. Please indicate if your child needs an inhaler, epipen, other medication for serious allergies, or none of the above

Does the child carry an epipen?

Yes

* Date of your child's last physical exam

Please provide us with a copy of your child's last medical exam. We are required to keep valid copies of medical exams on file at all times. For your convenience, the medical form has been emailed to you.

In the event of a serious accident or injury to a child enrolled in The Early Childhood Center at Temple Shaaray Tefila, it is the school's policy to immediately notify the parent or guardian and to call emergency medical care. It is possible that we will not be able to locate the parent or guardian immediately, therefore it is necessary to obtain parent or guardian authorization for emergency medical treatment in the parent's or guardian's absence. The authorization is kept on file, and in case of a serious accident, when the parent or guardian cannot be reached, this statement of authorization will be taken to the hospital with the child.

I hereby authorize emergency medical care and give permission to contact the child's physician on my behalf.

* Please type your name

* School District and School