Child Preadmission Form | Etowah Early Learn 1

Child's Name

Name(s) of parent(s)/ guardian(s)

Child's Birthday

Month

Day

Year

Phone

Address

Mother's Employer

Employer's address

Employer's telephone number

Father's Employer

Employer's address

Employer's telephone number

List telephone numbers such as beeper, cellphone, etc

Instructions regarding how parent/ guardian may be reached in an emergency

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

Please list Name, Relationship to child, Address, Telephone Number

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

Please list Name, Relationship to child, Address, Telephone Number

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

Please list Name, Relationship to child, Address, Telephone Number

Name of child's doctor

Address

Telephone Number

Signature

Signature field is empty.

I give permission for the child 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.)

Date

Month

Day

Year

Etowah Early Learning Academy