CAROUSEL KIDS

Vehicle Emergency Medical Information

Childs Name_______________________________________________Date of Birth____________________

Address_________________________________________________________________________________
Fathers Name____________________________________________________________________________
Home Phone________________________________Work Phone___________________________________
Mothers Name____________________________________________________________________________
Home Phone________________________________Work Phone___________________________________
Person to notify in an emergency and parents cannot be reached:
Name__________________________________________Phone____________________________________
Childs Doctor___________________________________Phone____________________________________

Medical Facility this center uses:

GWINNETT MEDICAL CENTER
1000 MEDICAL CENTER BLVD.
LAWRENCEVILLE, GA 30045
(770) 995-4321

Childs Allergies___________________________________________________________________________
Current Prescribed Medication(s)_____________________________________________________________
Childs Special Needs and Conditions__________________________________________________________

In the event of an emergency involving my child, and if Carousel Kids, Inc. cannot get in touch with me, I
hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical
expenses incurred during the treatment of my child.

Childs Name_____________________________________________________________________________
Signature (Parent/Guardian)_________________________________________________________________
Witnessed By___________________________________________________Date______________________