RSP ID Emergency Contact

To Be Completed by Parent or Authorized Representative

Child's Name:(Required)
Birthdate:(Required)
Address:(Required)
Father's/Guardian's/Father's Domestic Partner's Name:(Required)
Address:(Required)
Mother's/Guardian's/Mother's Domestic Partner's Name:(Required)
Address:(Required)
Person Responsible For Child:(Required)

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

Additional Persons Who May Be Called In An Emergency
Name
Address
Telephone
Relationship
 

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

Address:(Required)
Address:(Required)
If Physician cannot be reached, what action should be taken?(Required)

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)
Persons authorized to take child from facility:(Required)
Name
Relationship
 
Date:(Required)

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

Date of Admission: Date Left: