Emergency Care

Location Selection:(Required)

THE COMMONWEALTH OF MASSACHUSETTS
Department of Early Education and Care

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM

Child's Name:(Required)

Date of Birth:(Required)

Preferred Medical Care Facility:(Required)

Child's Physician Name:(Required)

Address:(Required)

Phone Number:(Required)

Child's Allergies:(Required)

Chronic Health Conditions:(Required)

Emergency Contacts (In order to be contacted)

Name:

Address:

Relationship to child:

Home Phone:

Cell Phone:

Do you give permission for child to be released to this person?

Yes

Name:

Address:

Relationship to child:

Home Phone:

Cell Phone:

Do you give permission for child to be released to this person?

Yes

Name:

Address:

Relationship to child:

Home Phone:

Cell Phone:

Do you give permission for child to be released to this person?

Yes

Health Insurance Information

Health Insurance Coverage:(Required)

Policy #:(Required)

Parent/Guardian Name:(Required)

Phone:(Required)

Cell:(Required)

Parent/Guardian Name:

Phone:

Cell:

Parent /Guardian Signature:(Required)

Date (valid for one year):(Required)

Emergency Care

KBLC Kingston

KBLC Norwell

KBLC Pembroke

KBLC Plymouth

KBLC Carver

KBLC Kingston

KBLC Norwell

KBLC Pembroke

KBLC Plymouth

KBLC Carver

KBLC Hanover

Have Questions?

KBLC Kingston

KBLC Norwell

KBLC Pembroke

KBLC Plymouth

KBLC Carver

KBLC Hanover