VEHICLE EMERGENCY MEDICAL INFORMATION

CHILD’S NAME : ______________________________ DOB____/____/_____

ADDRESS:_____________________________________________________________

PARENTS NAME

FATHER :__________________________________HOME:_____________________                                                                          WORK PHONE: ____________________

MOTHER:__________________________________ HOME:____________________

                                                                        WORK PHONE:_____________________

In any emergency and parents cannot be reached:

NAME: _______________________________________PHONE: _________________

CHILD’S DOCTOR:___________________________ PHONE:__________________

MEDICAL FACILITY THE CENTER USES: Eastside Medical Center

Address: 1700 Medical Way, Snellville GA

                                                                                                                                CHILD’S ALLERGIES:__________________________________________________

MEDICATION:___________________________________________________

CHILD’S SPECIAL NEEDS AND CONDITIONS:_______________________

_____________________________________________________________________

In any event of an emergency involving my child, and Lil’ People Daycare Center cannot get in touch with me , I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.

SIGNATURE OF PARENT OR GUARDIAN: _____________________________________________

INSURANCE INFO : POLICY#____________________________CARRIER:________________________________________

PHONE #: _______________________________________________

WITNESSED BY: ________________________________________  DATE:______________________

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