I/We ____________________________ hereby give permission to Pamela Ball and/or agent to call my/our physician for medical advice should any situation arise. I/We also give permission to Pamela Ball to discuss with my/our doctor or any other health care personnel, any situation or concerns she may have regarding the well being of my/our child _____________________. I/We hereby release Pamela Ball  and/or agent from any liability in any situation regarding the health of my/our child ____________________________, including but not limited to known or unknown allergies to prescription or over-the-counter medications.

I/We _____________________________________ hereby give my/our permission for my/our child _____________________________________ to be given emergency treatment (First Aid and CPR) by a qualified staff member at Pam’s Play Place and Preschool, as needed.

I/We ______________________________ also give my/our permission for my/our child ______________________ to be transported by ambulance and treated by EMT staff as needed to an emergency center in the case of an emergency, which can not be handled at Pam’s Play Place and Preschool, or by the staff.

In the event that I/we can not be reached, I/We _______________________ further give consent to the medical, surgical, and hospital staff to provide any treatment or procedures, which are deemed necessary or advisable by the physician to safeguard my/our child’s health.

In the event of an emergency and if emergency transportation is needed, I/we ___________________________ agree to pay all costs involved either with insurance or privately.

Information that might be needed if an emergency arises:

Child’s Physician:

Name _____________________________________ Phone ________________________________

Address _________________________________ City _______________ Zip Code _____________

Preferred Hospital: (If there is time for a choice)

Name _____________________________________ Phone ________________________________

Address _________________________________ City _______________ Zip Code _____________

Medical Insurance: (Please provide a copy of your insurance card)

Name of Company _______________________________ Policy # ______________________

Address _________________________________ City _______________ Zip Code _____________

Phone ________________________________

Date of last Tetanus ____________________________________

Allergies (Food or Medicine)__________________________________________________________

__________________________________________________________________________________

(Mother/Guardian)                                                                    (Date)

(Father/Guardian)                                                                     (Date)

(Pamela Ball)                                                                             (Date)

Note - Each family complete 3 copies, per child of this form. I place one in the Child's File, one goes with us on outings and the last one is for an actual emergency.

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