Fillable Child Emergency Information Form To be completed by (University of California, San Francisco)

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Child Emergency Information Form To be completed by (University of California, San Francisco)

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CHILD’S INFORMATION
CHILD’S FIRST AND LAST NAME NICKNAME DATE OF BIRTH
HOME ADDRESS
HOME PHONE
PARENT/GUARDIAN CONTACT INFORMATION
FIRST AND LAST NAME
WORK PHONE HOME PHONE CELL PHONE E-MAIL
FIRST AND LAST NAME
WORK PHONE HOME PHONE CELL PHONE E-MAIL
EMERGENCY CONTACT INFORMATION (CHILD MAY BE RELEASED TO THE PERSONS BELOW IF PARENT/GUARDIAN IS UNAVAILABLE)
FIRST AND LAST NAME RELATIONSHIP TO CHILD
ADDRESS E-MAIL
HOME PHONE CELL PHONE WORK PHONE
FIRST AND LAST NAME RELATIONSHIP TO CHILD
ADDRESS E-MAIL
HOME PHONE CELL PHONE WORK PHONE
FIRST AND LAST NAME RELATIONSHIP TO CHILD
ADDRESS E-MAIL
HOME PHONE CELL PHONE WORK PHONE
OUT-OF-AREA CONTACT (IN CASE LOCAL CALLS CANNOT BE MADE)
FIRST AND LAST NAME RELATIONSHIP TO CHILD
ADDRESS E-MAIL
HOME PHONE CELL PHONE WORK PHONE
CHILD’S MEDICAL CARE
PHYSICIAN’S NAME
PHONE NUMBER
ADDRESS
E-MAIL
WEBSITE
MEDICAL CONDITIONS, SPECIAL NEEDS, ALLERGIES, MEDICATIONS, ETC.
DENTIST’S NAME PHONE NUMBER
ADDRESS
E-MAIL
WEBSITE
HOSPITAL NAME
PHONE NUMBER
ADDRESS
I grant permission for the child care program to provide or arrange for medical treatment and/or transportation to an evacuation site and/or medical facility for my child during an
emergency or disaster. I grant permission for my child to be released to any of the emergency contacts designated above if I am unable to pick them up in an emergency.
PARENT/GUARDIAN
NAME (Please print)
SIGNATURE DATE
PARENT/GUARDIAN
NAME (Please print)
SIGNATURE DATE
Child Emergency Information Form — To be completed by parent or guardian
Child Care Resource Center, Emergency Preparedness Toolkit for Child Care Programs, funded by Los Angeles County Department of Public Health
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Child Emergency Information Form To be completed by (University of California, San Francisco)

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Completed 15 June 2021

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