"First Aid and Emergency Medical Care Consent Form - Wollaston Child Care Center" - Massachusetts

First Aid and Emergency Medical Care Consent Form - Wollaston Child Care Center is a legal document that was released by the Massachusetts Department of Early Education and Care - a government authority operating within Massachusetts.

Form Details:

  • Released on January 22, 2010;
  • The latest edition currently provided by the Massachusetts Department of Early Education and Care;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Early Education and Care.

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Download "First Aid and Emergency Medical Care Consent Form - Wollaston Child Care Center" - Massachusetts

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Wollaston Child Care Center
THE COMMONWEALTH OF MASSACHUSETTS
Department of Early Education and Care
FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM
Child's Name: _______________________________ Date of Birth: ___________________
I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first
aid/CPR when appropriate.
I understand that every effort will be made to contact me in the event of an emergency requiring medical
attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to
the nearest medical care facility and/or to ________________________, and to secure necessary medical
treatment for my child.
Child's Physician Name: ________________________________________________________
Address: ____________________________________________________________________
Phone Number: _______________________
Child's Allergies: ______________________________________________________________
Chronic Health Conditions: ______________________________________________________
Emergency Contacts (In order to be contacted)
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No______
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No_____
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No___
Health Insurance Coverage___________________________________ Policy #________________
Parent/Guardian Name: ________________________________ Phone__________ Cell___________
Parent/Guardian Name: ________________________________ Phone__________ Cell___________
___________________________________________
_________________________
Parent /Guardian Signature
Date (valid for one year)
SG/LG/SAEmergencyMedicalConsent20100122
Wollaston Child Care Center
THE COMMONWEALTH OF MASSACHUSETTS
Department of Early Education and Care
FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM
Child's Name: _______________________________ Date of Birth: ___________________
I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first
aid/CPR when appropriate.
I understand that every effort will be made to contact me in the event of an emergency requiring medical
attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to
the nearest medical care facility and/or to ________________________, and to secure necessary medical
treatment for my child.
Child's Physician Name: ________________________________________________________
Address: ____________________________________________________________________
Phone Number: _______________________
Child's Allergies: ______________________________________________________________
Chronic Health Conditions: ______________________________________________________
Emergency Contacts (In order to be contacted)
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No______
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No_____
Name_______________________________________________________________________
Address_____________________________________________________________________
Relationship to child____________________________________________________________
Home Phone__________________________ Cell Phone______________________________
Do you give permission for child to be released to this person?
Yes_____
No___
Health Insurance Coverage___________________________________ Policy #________________
Parent/Guardian Name: ________________________________ Phone__________ Cell___________
Parent/Guardian Name: ________________________________ Phone__________ Cell___________
___________________________________________
_________________________
Parent /Guardian Signature
Date (valid for one year)
SG/LG/SAEmergencyMedicalConsent20100122