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:
- 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
Address
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