Medical Emergency Form

Child's Info
Name*
First Last
List all known allergies*
Any problems in infancy/physical development etc.*
Has your child ever been hospitalized or had any serious illness? Please explain.*
Does your child take any medication on a regular basis*
- Yes
- No
Consent*
I authorize the CELC Staff to apply creams such as diaper cream, arnica, sunscreen and the like on my child.
Parent/Guardian Signature **
Date*
MM slash DD slash YYYY
Consent*
I authorize the CELC staff to administer prescription or patent medicine to my child as specified in a doctor's written prescription.
Parent/Guardian Signature **
Date*
MM slash DD slash YYYY
Consent*
If parents cannot be reached and emergency medical advice is needed, permission is given to the preschool staff to phone my child’s doctor:
Doctors Name:*
Doctor's Phone*
Doctor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Hospital Affiliation:*
Emergency Contact Information:
Other persons who Chabad Center Preschool is authorized to contact for guidance in an emergency, such as a medical or other emergency, when this child’s parents are unavailable.
Name*
First Last
Phone*
Relationship*
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
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Registration

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