Parental Consent – The Pittsburgh After School Academy

EMERGENCY CONTACT / PARENTAL CONSENT FORM

55 PA CODE CHAPTERS 3270.124 (a) (b), 3270.181 & 182; 3280.124 (a) (b), 3280.181 & .182; 3290.124 (a) (b), 3290.181 & .182

"*" indicates required fields

Child's Name*

Date of Birth*

Address*

Parent’s name / Legal guardian*

Home Telephone Number*

Address*

Business Name*

Business Telephone Number*

Address*

Parent’s name / Legal guardian*

Home Telephone Number*

Address*

Business Name*

Business Telephone Number*

Address*

Emergency Contact Person(s)

Name

Telephone number when child is in care

Emergency Contact Person(s)*

Person(s) to whom child may be released

Name

Address

Telephone number when child is in care

Person(s) to whom child may be released*

Name of child’s physician/medical care provider*

Telephone number*

Address*

Special disabilities (if any)*

Allergies (including medication reaction)*

Medical or dietary information necessary in an emergency situation*

Medication, special situation*

Additional information on special needs of child*

Health insurance coverage for child or medical assistance benefits*

Policy number*

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

Obtaining emergency medical care*

Admin. of minor first-aid procedures*

PERIODIC REVIEW

Signature of Parent or Guardian*

Date*

WHITE COPY (Original)

YELLOW COPY (Child Care Space)

PINK COPY (Excursion)

CY 867 10/22