Tiny Tots 
Preschool 

                   WE MAKE LEARNING FUN!



THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care



FIRST AID AND EMERGENCY MEDICAL CARE CONSENT:


  • I authorize staff at TINY TOTS PRESCHOOL  who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to ________________________, and to secure necessary medical treatment for my child.

CHILD'S NAME  ______________________________________ DOB ________________________

Child’s Physician:___________________________________________________________________

Address:_______________________________________ Phone #:________________________

  • Allergies/Special Diets?___________________________________________________________
  • Chronic health condition? (If yes, please attach Individual Health Care Plan)
  • Regular Medication:______________________________________________________________


EMERGENCY CONTACTS: (In addition to parents/guardians, the following can be contacted in the event of an emergency)


Name_________________________________________________________________________

Address________________________________________________________________________

Relationship to child_____________________________________________________________

Home Phone_______________________________ Cell #:______________________________

Do you give permission for child to be released to this person? Yes_____ No______


Name_________________________________________________________________________

Address________________________________________________________________________

Relationship to child_____________________________________________________________

Home Phone_______________________________ Cell #:______________________________

Do you give permission for child to be released to this person? Yes_____ No______


Name_________________________________________________________________________

Address_______________________________________________________________________ 

Relationship to child_____________________________________________________________

Home Phone_______________________________ Cell #:______________________________

Do you give permission for child to be released to this person? Yes_____ No______



HEALTH INSURANCE COVERAGE _______________________ POLICY # ________________

Parent/Guardian Name ___________________________ phone/cell ______________________

Parent/Guardian Name ___________________________ phone/cell ______________________


_______________________________________________     ____________________________

PARENT/GUARDIAN SIGNATURE  __________________________________DATE _________