Emergency Form

PLEASE STAR THE PHONE NUMBER YOU CAN BE REACHED AT MOST EASILY DURING THE DAYS YOUR CHILD WILL BE ATTENDING THE COTTAGE GARDEN.

Date

MM

DD

YYYY

Child's Name

First Name

Last Name

Child's Gender

Child's Date of Birth

MM

DD

YYYY

I hereby give Celia Riahi and members of her staff permission to administer basic first aid and/or CPR to my child and/or to take my child to a hospital for medical treatment when I cannot be reached or when delay would be dangerous to my child’s health.

I Do Give Permission

Name Of First Parent/Guardian

First Name

Last Name

Address Of First Parent/Gaurdian

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Of First Parent/Guardian

(###)

###

####

Work Phone Of First Parent/Guardian

(###)

###

####

Cell Phone Of First Parent/Guardian

(###)

###

####

Email Of First Parent/Guardian:

Name Of Second Parent/Guardian:

First Name

Last Name

Address Of Second Parent/Guardian:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Of Second Parent/Guardian:

(###)

###

####

Work Phone Of Second Parent/Guardian:

(###)

###

####

Cell Phone Of Second Parent/Guardian:

(###)

###

####

Email Of Second Parent/Guardian:

Physician’s Name

First Name

Last Name

Hospital Affiliation of Physician

Hospital Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone To Reach Physician

(###)

###

####

Name Of First Emergency Contact (local, if possible)

First Name

Last Name

Phone Number Of First Emergency Contact

(###)

###

####

First Emergency Contact's Relationship To The Child

Name Of Second Emergency Contact (local, if possible)

First Name

Last Name

Phone Number Of Second Emergency Contact

(###)

###

####

Second Emergency Contact's Relationship To The Child

Name Of Third Emergency Contact

First Name

Last Name

Phone Number Of Third Emergency Contact

(###)

###

####

Third Emergency Contact's Relationship To The Child

Parent Signature

Please supply a WRITTEN & SIGNED NOTE from your health care provider for my records if your child:

Has any allergies, specifically to what and what he/she can and can’t have?
Takes any prescribed medication?
Takes any Homeopathic Remedies?
Needs an EPI Pen on site

Please also send a copy of your child’s Health Record and Immunizations or letter of exemption based on your religious beliefs. Proof and result of annual LEAD test must be submitted.

Emergency Form

The Cottage Garden // Celia Riahi