Emergency Contact & Consent - 2025-26 Washington Park Early Learning Center

1Family Information

2Emergency Contacts

3Medical Information

4Submit Form

Child's Full Name*
First Middle Last
Which class is this child enrolled in for the upcoming school year?*
This form must be completed for each child attending WPELC for the upcoming school year.
Parent / Guardian
In case of emergency, the parent(s)/guardian(s) will be contacted first.
Name*
First Last
Main Phone*
Secondary Phone
Email*
Work Address*
If this parent has no work address, please provide home address.

Street Address Address Line 2 City State ZIP Code
Does this child have a second parent/guardian?*
- Yes
- No
Name*
First Last
Main Phone*
Secondary Phone
Email*
Work Address*
If this parent has no work address, please provide home address.

Street Address Address Line 2 City State ZIP Code

Emergency Contacts
Emergency Contacts can assume responsibility of the child in the event of an emergency if the parent(s)/guardian(s) cannot be reached immediately. You must provide at least one Emergency Contact for your child.
Name*
First Last
Relationship to Student/Family*
Address*
Street Address City State ZIP Code
Phone*
Do you wish to authorize a second adult to be an Emergency Contact?*
- Yes
- No
Name*
First Last
Relationship to Student/Family*
Address*
Street Address City State ZIP Code
Phone*
Do you wish to authorize a third adult to be an Emergency Contact?*
- Yes
- No
Name*
First Last
Relationship to Student/Family*
Address*
Street Address City State ZIP Code
Phone*
Do you wish to authorize a fourth adult to be an Emergency Contact?*
- Yes
- No
Name*
First Last
Relationship to Student/Family*
Address*
Street Address City State ZIP Code
Phone*

Physician Information
Physician's Name*
Physician's Phone*
Physician's Address*
Street Address City State ZIP Code
Dentist Information
Dentist's Name*
Dentist's Phone*
Dentist's Address*
Street Address City State ZIP Code
Preferred Hospital
You must provide a hospital of choice for use in the event this child requires emergency care.
Preferred Hospital's Name*
Hospital's Phone*
Hospital's Address*
Street Address City State ZIP Code
Medical Information
Does this child have any known drug or food allergies?*
- Yes
- No
Please list all allergies:*
Reactions:*
Made better by (resolved with, or improved by):*
Does this child require prescription and/or non-prescription (over-the-counter) medications?*
- Yes
- No
What medications are required?*
In the event medications may need to be administered while in school or at summer camp, you must submit a signed Health Care Plan, which includes permission to administer medicine, from your child’s medical provider.

Parent / Guardian