The Learning Garden 2014-2014

Emergency Form
Childs name:_______________________________________ Birth date:_______________ F /M
Nickname:__________________________________________
Address:_______________________________________________________________________
Parents email address: ___________________________________________________________
Mothers name_______________________
Mothers work phone:_______________________
Fathers name:_______________________
Fathers work phone:_______________________
Home phone:_______________ Mothers cell: _______________Fathers cell: _______________

Emergency Information
Names of persons to contact in case of emergency:
Name
Phone
Relationship
1. ______________________________________________________________________________
2. ______________________________________________________________________________
Name of childs physician: ____________________________ Phone: ____________________________
Does your child have any allergies? (include foods, medicines, insect bites):
_______________________________________________________________________________________

Emergency Release
Consent to Emergency First Aid & Transportation
I hereby give my permission that my child may be given emergency treatment by an employee of The
Learning Garden. I also give permission for my child to be transported by car or ambulance to an
emergency center for treatment.

I acknowledge that The Learning Garden, LLC will not be responsible for any medical expenses that
may be incurred.
Parent Signature:__________________________________________ Date:____________________

I hereby authorize The Learning Garden to allow my child to leave the operation ONLY with the following
persons. Please list name and telephone number for each. Children will only be released to a parent or person
designated by the parent/guardian after verification of ID.
1. ________________________________________________________________________
2. ________________________________________________________________________