Emergency Contact Form

Child Name*

First Last

Child Date of Birth*

Child Home Phone (or parent cell #)*

Child Address*

Street Address City State ZIP Code

Father's Name*

First Last

Father's Address*

Same as Child's (above)
Different than Child's (above)

Father's Address*

Street Address City State ZIP Code

Father's Email Address*

Father's Phone (Preferred number)*

Father's Phone (Backup / Second number)

Mother's Name*

First Last

Mother's Address

Same as Child's (above)
Different than Child's (above)

Mother's Address*

Street Address City State ZIP Code

Mother's Email Address*

Mother's Phone (Preferred number)*

Mother's Phone (Backup / Second number)

Guardian's Name

(optional)

First Last

Guardian Phone Number

List two persons who can be called in the event of an emergency and who would be authorized to pick your child up in your absence. YOUR CHILD MAY ONLY LEAVE THE FACILITY WITH THE PERSONS LISTED HERE.

Emergency Contact/Authorized Pickup 1

YOUR CHILD MAY ONLY LEAVE THE FACILITY WITH THE PERSONS LISTED HERE.

Name*

First Last

Address*

Street Address City State ZIP Code

Phone*

Email

Emergency Contact/Authorized Pickup 2

YOUR CHILD MAY ONLY LEAVE THE FACILITY WITH THE PERSONS LISTED HERE.

Name*

First Last

Address*

Street Address City State ZIP Code

Phone*

Email

I give consent for my child to participate in splash pools.*

Yes
No

I give consent for my child to participate in wading pools.*

Yes
No

Families are responsible for reading and complying with the contents of the Parent Handbook.*

I have read and accept the terms presented in the CRCDS Parent Handbook.

You may download the Parent Handbook here.

To provide your digital signature, please enter your full legal name, and date of birth below.*

Full Legal Name	Date of Birth

Does your child have ANY allergies? (food, medicine, environmental)*

Yes
No

Before being enrolled, you MUST fill out a FARE (food allergy and anaphylaxis emergency care plan) form for your child. You may download and print out the form here. Blank forms are also available at our office.

List any existing illness, previous serious illness OR injury, hospitalizations during the past twelve months, or medications prescribed for long-term continuous use. (Can list "none")*

What special assistance does your child require in order to participate in class/group activities? (Can list "none")*

Has your child been professionally tested or evaluated?*

Yes
No

If yes, please explain.

AUTHORIZATION FOR MEDICAL ATTENTION

In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to:

Name of Physician	Address	Phone

Name of Hospital	Address	Phone

I give consent for this facility to secure any and all necessary medical care for my child.*

To provide your digital signature, please enter your full legal name, and date of birth below.

Full Legal Name	Date of Birth

Bloomz App Permission

Your child's class will be using an app and web service called Bloomz to simplify how we communicate with you about your child and about his or her class. This is a secure app/website and will only be able to be viewed by the parents and teachers of your child's class. In order to join a class on Bloomz, you will have to be invited by us. We will send an email invite which will allow you to join.

I grant permission to share pictures of my child on the secure class Bloomz page.

Yes
No

I agree to respect the class Bloomz page and to contribute in a polite and positive manner. I will present any personal concerns in a private message to the teacher.

To provide your digital signature, please enter your full legal name, and today's date below.

Full Legal Name	Date of Birth

Emergency Contact/Authorized Pickup 1

Emergency Contact/Authorized Pickup 2

AUTHORIZATION FOR MEDICAL ATTENTION

Bloomz App Permission

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