Emergency Form - A Joyful Noise Preschool & Childcare

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Emergency Medical Treatment Authorization Form

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact them. This form should accompany the child in the event of off-site trips or emergency relocation of the program.

Child's Full Legal Name(Required)

First Last

Date of Birth(Required)

Gender

Female

Male

Parent 1(Required)

First Last

Parent 2 Name

First Last

Parent 1 Mobil Phone(Required)

Parent 2 Mobil Phone

Parent 1 Work Phone

Parent 2 Work Phone

Parent 1 Email(Required)

Parent 2 Email

Parent 1 Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent 2 Address

Street Address Address Line 2 City State ZIP Code

Physician's Name and Location of Practice(Required)

Physician's Phone Number(Required)

Dentist's Name and Location of Practice(Required)

Dentist's Phone Number(Required)

Medical Insurer/Health Plan:

Insurance Policy Number

Pharmacy

Pharmacy Address

Pharmacy Phone

Emergency Contact #1

Emergency Contact #2

Contact #1 Relationship to Child

Contact #2 Relationship to Child

Contact #1 Address

Street Address Address Line 2 City State ZIP Code

Contact #2 Address

Street Address Address Line 2 City State ZIP Code

Contact #1 Phone

Contact #2 Phone

Contact #1 Email

Contact #2 Email

Name any persons who are permitted to pick up your child other than you: (Click the plus to add names.)

Date of Last Physical

Allergies to Medications:

Allergies (other):

Please note all conditions for which child is currently receiving treatment:

Please note any other significant medical information:

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Consent

Emergency Authorization

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for A Joyful Noise Preschool and Childcare to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize A Joyful Noise Preschool and Childcare to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of A Joyful Noise Preschool and Childcare in the exercise of his or her best judgement upon the advice of any such medical or emergency personnel.

Signed this day of(Required)

This authorization is effective through

Parent/Legal Guardian Signature:

Printed Name:

First Last

Witness Signature:

Printed Name:

First Last

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