Calpella ElementaryUkiah Unified School District

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Forms » Emergency and Identification Information

Emergency and Identification Information

State Department of Education                                                                                                           To be completed by parent or guardian and

Child Development Division                                                                                                        updated at recertification and as changes occurs.

CD-9607 (Rev 09/05)


Emergency and Identification Information


I.    Family Information


Child’s name (Last, First, Middle):                                                                          Birth Date:                               


      Mother’s name:                                                                                                                                                  


      Father’s name:                                                                                                                                                   


      Child’s Address:                                                                                                  Phone:                                    


      Mother’s business address:                                                                                   Phone:                                    


      Father’s business address:                                                                                   Phone:                                    


  1. Names of Persons Authorized to Take Child from the Facility (This child will not be allowed to leave with any other person without written authorization from parent or guardian.)


                                        Name                                                     Telephone                                                    Relationship







III.    Additional Persons Who May Be Called in an Emergency to Take Child from the Facility


                                Name                                       Address                                              Telephone                                            Relationship







IV.    Physician to Be Called in an Emergency


Name                                                                                                                                 Telephone                                                                     





V.     Medi-Cal Number                                                                                                         Medical Insurance                                                     


Insurance Number                                                                                                    


VI.   Allergies or Other Medical Limitations  _______________________________________________________________




VII.  Permission for Medical Treatment  Administrative procedures vary among medical personnel and medical facilities with regard to provision of medical care for a child in the absence of the parent. The exact procedure required by the physician or hospital to be used in emergencies should be verified in advance.


In case of an accident or an emergency, I authorize a staff member of the child development agency to take my child to the above-named physician or to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of the child, at my expense.



Signature                                                                                            Date                                                                                                         

                                                Parent or Guardian