Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached

Emergency Authorization: I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)

I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The license of the child care facility assumes full responsibility for such activities.