RLCA Emergency Contact/Parental Consent Form

55 PA CODE CHAPTERS 3270.12 (a) (b), 3270. 181 & 182: 3280. 124 (a) (b), 3280. 181 & 182: 3290. 124 (a) (b), 3290. 181 & 182
Child's Name
MM slash DD slash YYYY
Address
Mother's Name/Legal Guardian
Address
Business Address
Father's Name/Legal Guardian
Address
Business Address
Emergency Contact Person(s)
Name
Telephone Number (When in care)
 
Person(s) Whom Child May Be Released
Name
Address
Telephone Number (When in care)
 
Address
If none, please write N/A
Obtaining emergency medical care
Administration of minor first-aid procedures
Walks and Trips
Swimming
Transportation by the facility
Wading