- MGLite

Child Enrollment Form

Emergency Medical Care Authorization

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Submission Details

Date of Application Automatically set to today's date.

Child's Information

Child's Full Name

Date of Birth

Home Phone

Home Address

Guardian 1

Same Address

Full Name

Home Address

Employer Name & Address

Guardian 2

Same Address

Full Name

Home Address

Employer Name & Address

Medical & Emergency Authorization

Physician Name & Phone

Dentist Name & Phone

Last Tetanus

Physician Address

Dentist Address

Insurance Carrier

Insurance ID #

Preferred Medical Facility

Known Allergies

I give consent for First Aid/CPR and transport to the nearest hospital in a medical emergency.

Weekly Care Schedule

Mon

Tue

Wed

Thu

Fri

Authorized Pickups These person(s) are permitted to remove child from childcare program on behalf of parent.

Emergency Contacts In an emergency, adult(s) to be contacted if parent cannot be reached and to whom the child can be released..

I acknowledge reading the parent handbook and agree to abide by center policies.

Parent Signature