Please print out these pages and fax to: 617.724.7171
| MGH BACKUP
CHILDCARE CENTER - Warren Lobby REGISTRATION AND EMERGENCY CONSENT FORM For The Safety Of Your Child(ren) It Is Imperative To Thoroughly Complete This Document |
For Employee: ID # _______________________________ Dept._________________________________
For Patient: Blue Card #:___________________________ Dept. _________________________________
Child(ren)'s First & Last Names: (Please list all
children in attendance)
1. ________________________________________________ DOB:
_____-_____-_____ Gender: ______
2. ________________________________________________ DOB:
_____-_____-_____ Gender: ______
3. ________________________________________________ DOB:
_____-_____-_____ Gender: ______
Employee E-mail address at work: _________________________________________________________
Parent/Guardian: #1__________________________________Work Phone: _________________________
Beeper #_____________________________________ Cell Phone: _______________________________
Home Address:_________________________ Apt. # _________ Home Phone # _____________________
City________________________________ State________________ Zip Code ______________________
Parent/Guardian: #2__________________________________Work Phone: ________________________
Beeper #_____________________________________ Cell Phone: _______________________________
Home Address:_________________________ Apt. # _________ Home Phone # _____________________
City________________________________ State________________ Zip Code ______________________
| CONTACT
INDIVIDUAL |
In the event that you leave your office or work area (i.e. lunch, meetings, etc.), who can we call to get in touch with you? Generally this person is a co-worker, administrative assistant, etc.
Name:_________________________________________ Work Phone # ___________________________
| ALLERGIES
/ EATING SCHEDULE |
Please list and verbally alert us to any allergies your child may have to food, medication, etc. Please check here if there are NO KNOWN ALLERGIES _______
Allergies:_________________________________ Reactions:_______________________________________
Special Notes Regarding Meals:_______________________________________________________________
| SLEEP
SCHEDULE |
Please list times of naps, special comfort items, as well as your usual routine for helping your child to sleep.
____________________________________________________________________________________
| MEDICAL
OR DEVELOPMENTAL CONDITIONS |
Please list and verbally alert us to any medical or developmental condition that could require special care or attention.
____________________________________________________________________________________________
| ANY
OTHER INFORMATION WE SHOULD KNOW ABOUT YOUR CHILD(REN) TO MAKE HIS/HER
STAY MORE ENJOYABLE |
Comments:_______________________________________________________________________________
| DIAPERING
/ TOILETING |
Any special instructions including ointments, wipes, powder, etc. Please note that in order for us to apply any topical's, you must first fill out a TOPICAL PERMISSION RELEASE. Please ask a teacher for this form.
Diapering: Usual Routine:________________________________________________________________
Toileting: Usual Routine:_________________________________________________________________
| MEDICATION |
Is your child currently taking any medications?__________ If so, Why?__________________________________
Name of medication __________________________________________________________________________
Please note: Staff can only administer prescription medication when it is in the original prescription container and accompanied by a completed AUTHORIZATION FOR MEDICATION, which we provide for you. Please ask a staff member about our specific medication policies so we can best serve you and your child.
It is essential to provide teachers with the above information at drop-off time, allowing them to offer the best possible care to your children. Please be sure to inform them of any unusual circumstances that might affect your child’s day. Thank you!
PLEASE GIVE ALL MEDICATIONS TO A TEACHER - NEVER LEAVE MEDICATIONS IN YOUR CHILD'S BAG OR CUBBY.
| EMERGENCY RELEASE INDIVIDUALS-OTHER THAN PARENT/GUARDIANS I hereby authorize the MGH Backup Child Care Center to release my child to the following persons. #1 Name:_____________________________________ Relationship to child:_________________________ Address:____________________________ City:______________________ State: ______ Zip:___________ Day Phone:________________Evening Phone:________________Cell
Phone: _______________________ #2 Name:_____________________________________ Relationship to child:_________________________ Address:____________________________ City:______________________ State: ______ Zip:___________ Day Phone:________________Evening Phone:________________Cell
Phone: _______________________ #3 Name:_____________________________________ Relationship to child:_________________________ Address:____________________________ City:______________________ State: ______ Zip:___________ Day Phone:_______________Evening Phone:_________________Cell Phone: _______________________ |
PARENT/GUARDIAN SIGNATURE:_____________________________ Print: ________________________________ Date: ______________
| MGH BACKUP CHILD CARE
CENTER-Warren Lobby EMERGENCY AUTHORIZATION AND CONSENT FORM |
NAME OF CHILD(REN):______________________________________________________________________________
I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child.However, if I cannot be reached, I hereby authorize the MGH Backup Child Care Center to transport my child to Massachusetts General Hospital or______________________________________ (name of hospital preferred) and to secure for my child the necessary medical treatment including anesthesia. I understand the teachers in the MGH Backup Child Care Center are trained in the basics of First Aid and I authorize them to give my child First Aid when appropriate.
Is your child allergic to any medications? If so please state:
Allergy: ___________________________________________ Reaction: ____________________________________
PARENT/GUARDIAN SIGNATURE:_____________________________ Print: ________________________________ Date: ______________
MEDICAL INSURANCE WITH:________________________________ POLICY NUMBER:__________________________
DOCTOR'S NAME:_______________________________________
DOCTOR'S ADDRESS:____________________________________
DOCTOR'S PHONE:__________________
CHILD'S MGH MEDICAL NUMBER: (if applicable) ________________________________
PARENT/GUARDIAN SIGNATURE:_____________________________
Print: ________________________________ Date: ______________