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ECDC Emergency Contact/Parental Consent 2021-2022
Please complete a separate form for each child.
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* Indicates required question
Child's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Parent/Legal Guardian 1's Name
*
Your answer
Home Telephone Number
*
Your answer
Cell Phone Number
*
Your answer
Home Address
*
Your answer
Business Telephone Number
Your answer
Business Name and Address
Your answer
Email
*
Your answer
Parent/Legal Guardian 2's Name
Your answer
Home Telephone Number
Your answer
Cell Phone Number
Your answer
Home Address
Your answer
Business Telephone Number
Your answer
Business Name and Address
Your answer
Email
Your answer
Emergency Contact Person(s)
*
Include name(s) and telephone number(s) when child is in care.
Your answer
Person(s) To Whom Child May Be Released
Include name(s), address(es) and telephone number(s) when child is in care.
Your answer
Name of Child's Physician/Medical Care Provider
*
Your answer
Telephone Number
*
Your answer
Address
*
Your answer
Special Disabilities (If Any)
*
Your answer
Allergies (Including Medication Reaction)
*
Your answer
Medical or Dietary Information Necessary in an Emergency Situation
*
Your answer
Medication, Special Conditions
*
Your answer
Additional Information on Special Needs of Child
Your answer
Health Insurance Coverage for Child or Medical Assistance Benefits
*
Your answer
Policy Number
Your answer
Signature of Parent or Guardian
*
Your answer
Date
*
MM
/
DD
/
YYYY
Signature of Parent or Guardian
Your answer
Date
MM
/
DD
/
YYYY
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