Emergency Contact & Consent - 2023-2024 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 2023-2024 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
Please provide any special instructions regarding how parents/guardians can be reached while this child is at WPELC.

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 camp, you must complete a Permission to Administer Medicine Form.

Parent / Guardian