Parent Authorization for Emergency Treatment and Medicine

In consideration of admittance, I hereby authorize ME TOO PRESCHOOL INC. to arrange medical examination, medicine and/or treatment of my child, __________________________ should an emergency arise while in the center’s care.  It is understood that a conscientious effort will be made by the child care center to contact me at the emergency numbers I have provided below before any medical action is taken.

I would prefer my child be taken to the following hospital if the need arises:_______________.  I understand that choice of hospital may be limited by service, need or local rescue squad.

I give ME TOO PRESCHOOL authorization to treat my child with topical ointment for cuts/abrasions in typical play and/or treat my child in other situations as instructed by 911 or the Poison Control Center.

Mother/Guardian Signature _______________________ Date __________________________

Home Phone ________________Cell Phone ______________  Work Phone ________________

Father/Guardian Signature ________________________ Date __________________________

Home Phone ________________Cell Phone ______________  Work Phone ________________

Health Insurance Plan_____________________ Policy Number __________________________

Relatives or other persons to be contacted in case of emergency:

______________________________________________________________________________

            Name              Relation to Child                     Address                       Phone (Home/Cell)

______________________________________________________________________________

            Name               Relation to Child                     Address                       Phone (Home/Cell)

______________________________________________________________________________

            Name              Relation to Child                     Address                       Phone (Home/Cell)

______________________________________________________________________________

            Name              Relation to Child                     Address                       Phone (Home/Cell)

Photo/Video Release Form

I CONSENT or DO NOT CONSENT permission for my child, __________________, to be photographed/video recorded for purposes such as field trip activities or school activities.  I agree that this form will remain in effect during the term of my child’s enrollment.  I understand that there will be no payment for me or my child’s participation in this release.

Parent/Guardian Signature ______________________ Date _________________