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Child Care Emergency Form Template

Ensure Swift Action and Child Safety with This Template

When a child faces a medical emergency, timely communication with caregivers is crucial. This Child Care Emergency Form Template is designed for parents needing to inform daycare providers about specific medical conditions and emergency contacts, ensuring your child's safety is prioritized. With this streamlined form, you can securely share critical information, streamline communication, and make the admission process quicker while adhering to compliance standards, like WCAG-aligned labels. Experience peace of mind by using the live template to prepare for the unexpected.

Use this Template (FREE) Live Preview
Child full name
Child date of birth
Home address
Child gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary parent/guardian full name
Mobile phone
Relationship to child
Mother
Father
Legal guardian
Stepparent
Grandparent
Aunt/Uncle
Sibling
Family friend
Other
Please Specify:
Emergency contact 1 full name
Emergency contact 1 relationship to child
Grandparent
Aunt/Uncle
Sibling
Family friend
Neighbor
Nanny/Babysitter
Other
Please Specify:
Emergency contact 1 phone
Emergency contact 2 full name
Emergency contact 2 phone
Emergency contact 2 relationship to child
Grandparent
Aunt/Uncle
Sibling
Family friend
Neighbor
Nanny/Babysitter
Other
Please Specify:
Allergies and medical conditions (include any special needs)
Current medications (name, dose, schedule)
Primary physician full name
Physician phone
Health insurance provider
Policy number
Consent to emergency medical treatment
Yes
No
Consent for basic first aid (bandages, ice packs)
Yes
No
I authorize the listed emergency contacts to pick up my child
Yes
No
Parent/guardian name (signature)
Date
I certify the information provided is accurate and will be updated as needed
Yes
No
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Paper art illustration featuring a child care emergency form template with colorful design elements and clear text sections.

When to use this form

When you care for children, every minute counts in a crisis. Use this form at enrollment, the start of each term, field trips, and after any health change. It captures emergency contacts, authorized pick-up adults, doctors, medications, and consent to treat. It helps teachers, aides, and drivers act fast and follow policy if a child is hurt or ill. Pair it with the Daycare allergy form to record triggers and EpiPen steps. Keep rosters aligned with the Daycare attendance form so you can reach the right guardian during a lockdown or evacuation. If you run an after-school program, align pick-up instructions with the After school care sign out sheet form.

Must Ask Child Care Emergency Questions

  1. Who are your child's primary and backup emergency contacts, and what are their phone numbers?

    Clear call order and multiple numbers speed response when seconds matter. During drills and evacuations, pair this with the Safety attendance form to account for each child and notify guardians fast.

  2. Which adults are authorized to pick up your child, and who is restricted?

    This prevents release to the wrong person and avoids custody conflicts. Staff can match photo IDs to your list and follow the same steps at sign-out.

  3. Does your child have allergies, medical conditions, or medications, and what are the treatment steps?

    Listing symptoms, dosing, and triggers reduces errors in stressful moments. It also tells substitutes exactly what to do if you are not on site.

  4. Who is your child's physician, preferred hospital, and insurance details?

    Sharing this upfront speeds intake and coverage checks at the ER. It helps paramedics and clinics coordinate care without delay.

  5. Do you grant consent for emergency evaluation and treatment, including transport by EMS?

    Written consent lets providers act when you cannot be reached. It removes hesitation and reduces liability for you and the center.

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