Out of School Care Emergency Consent Form

Please review the following information, edit and click submit at the bottom.

Last Name *

Child's First Name *

Birthdate: * +

Child lives with: (names & relationship) *

Main Contact Phone Number *

Street Address *

City *

Postal Code *

Parent 1 First Name(s) *

Parent 1 Last Name *

Cell 1 Number *

Parent 2 First Name(s)

Parent 2 Last Name

Cell 2 Number

Emergency Contact 1 Name: *

Phone Number: *

Doctor's Name: *

Doctor's Phone Number: *

Care card number *

Allergies or medical concerns? *

Emergency Centre Consent *

I hereby give consent for my child to be taken to the nearest emergency centre when I cannot be contacted. Any associated costs incurred as a result of of emergency transportation or medical treatment for the child is the responsibility of the child's parent/guardian.

Medical treatment consent *

I hereby give consent for my child to receive medical treatment.

Signature: *

clear

Pick up contact 1 name:

Phone Number:

Pick up contact 2 name:

Phone Number:

Pick up contact 3 name:

Phone Number: