DPS Emergency Enrollment Form

Enrollment Date:
_________________

Student Information
Last Name First Name Birthdate Sex
Allergies Medication(s)

Parent / Guardian
Name Relationship to Student
Address
Cell Phone Home Phone
Email Address

Employer Employment Address Work Phone

Parent / Guardian
Name Relationship to Student
Address
Cell Phone Home Phone
Email Address
Employer Employment Address Work Phone
 Emergency Contacts
If you, the parents/legal guardian, cannot be reached, two people who can assume responsibility for your child in
the event of an emergency are:
1. Name Relationship
Address Phone

2. Name Relationship
Address Phone

Pick-up Authorization
Persons, if any, other than parents/legal guardians, authorized to pick this child up from DPS Drop-In are:
1. Name Relationship

Address Phone
2. Name Relationship
Address Phone

Medical Information
Physician Name Address Phone
Hospital of Choice Address Phone

Dentist Address Phone

Does your child have any life-threatening allergies that require medication? NO/YES
If yes, please explain
Does your child have dietary restrictions, or any chronic health condition, or special need? NO / YES
If yes, please explain

I affirm that my children’s immunization record or documentation of exemption is on file with Denver
Public Schools.

Authorization for emergency medical care and transportation

In the event of an emergency, I hereby give my permission for child care staff to access emergency medical
services for my child, including transport to the nearest health care facility, to receive emergency medical or
surgical care and treatment. It is understood that conscientious effort will be made to locate me, and I
accept the expense of care and transport.
By signing below I agree that this information is true and accurate.

Signed Parent or Legal Guardian Date _________