Emergency Information Card
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Whaley's World of Fun Daycare |
Caregiver Name: Stephanie Whaley |
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Address:2333 S. Hilton Ave. Springfield |
Phone:(417)368-1600 |
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Child's Name: | |
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Date of Birth: |
Home Phone: |
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Address: | |
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Mother's Name: |
Work Phone: |
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Father's Name: |
Work Phone: |
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Emergency Contact: |
Daytime Phone: |
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Child's Doctor: |
Phone: |
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Medical Card #: |
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Allergies: | |
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Medical Conditions: | |
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Medications: | |
GENERAL TRANSPORTATION AUTHORIZATION
I,We _________________________________authorize Stephanie Whaley owner of Whaley's World of Fun Daycare or an Adult Helper at
Whaley's World of Fun Daycare permission for my/our child/children, ___________________________________, age ______, authorize my
child/children to ride as a passenger in a vehicle owned, leased, on Public Transportation or (School Bus) by the above named business for
the following Reason's:
Transporting to outside activities (Taking to and from Sherwood El. School, Sports Practices, Swimming Lessons,
parks, walking places, ect.)
Transporting any child, to obtain Medical Treatment
Any Reason The Provider Wishes to Transport.
Other (List):_______________________________________________________________________
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I UNDERSTAND THAT THE PROVIDER WILL ALWAYS USE PROPER SAFETY RESTRAINTS , AND WILL NEVER LEAVE ANY CHILD
UNATTENDED IN A VEHICLE.
_____ Give Permission for my/our child, ____________________________, to Participate in activities geared for my child/children, inside
Daycare Provider's Home, outside Daycare Provider's Home,or away from the Daycare Provider's home. I Understand that these activities
will be in the immediate neighborhood, and My Provider or My Providers Adult Helper will be present during these activities. These activities
specifically include:
Play inside as well as outside the Daycare Provider's home, Walk around the Neighborhood.
Walks to The Neighborhood Parks to Play, Play with water, ect.
Other (List):_______________________________________________________________________
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MEDICAL EMERGENCIES: Although supervision is constantly given, I cannot be by the child’s side at all times to prevent falls, tripping,
bumps, blows from other children, includes transportation, parks, play centers, etc. If the child is injured in a non life-threatening way, I will
assess the child and provide home first aid. If the injury is more serious, the parent will be notified so the child can be transported to the
hospital or doctor’s office. (I.E. needs stitches, broken arm, or dislocation, etc.) All costs associated with injuries to the child will be the
responsibility of the parent. In case of a medical emergency, I will attempt to call you immediately. If I am unable to reach you, I will start
calling the people designated as your emergency contacts. If I am unable reach, you or your emergency contacts, and immediate intervention
is required. I will take appropriate action including calling 911 and having your child transported to the nearest Hospital by ambulance. You or
your family insurance is/are responsible for the cost of medical help or treatment due to accidents or illness while in childcare.
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Parent/Parent's Signature Date
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Provider's Signature Date
