Childcare Pre-Enrollment Application

Person(s) to be contacted in emergency if parent(s)/guardian(s) cannot be reached:


Emergency Authorization

I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. I give permission for the care facility to administer Syrup of Ipecac to my child in accordance with instructions from the poison control center. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.