EMERGENCY FORM

Childs Name__________________________
If your child requires medical care, the following procedures will be followed: You will be called
immediately. If I cannot reach you, your childs family doctor will be called at:
Name_________________________________________________________________________
Address_______________________________________________________________________
Phone#_______________________________
If the doctor is not available, the child will be taken to the nearest hospital emergency room for
treatment.
Nearest Hospital: Peconic Bay Medical Center, Riverhead, NY 11901
Health Insurance Carrier__________________________________________________________
Insureds Name_________________________________________________________________
Policy Number____________________________

EMERGENCY RELEASE FORM

I hereby give my consent to Happy Earth Playschool to authorize medical, surgical, and or
dental treatment including hospitalization for my child,_________________________, should it
be necessary while my child is in their care.
Parent/Guardian: ____________________________________________________________
Parent/Guardian Signature: ___________________________________________________
Date: __________________________

Happy Earth Playschool, 131 Linda Avenue, Riverhead, NY 11901, 631.779.2643