Emergency Contact Information

Child's Name(Required)

First Last

Child's Doctor Name(Required)

First Last

Doctor's Phone(Required)

Doctor's Full Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Concent for Emergency Treatment

If emergency medical care becomes necessary, I authorize UWM and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be administered upon the advice of a physician and/or to be transported to a hospital at the discretion of police and/or fire department paramedics or EMT’s. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered.

Date

How many Pick-up/Emergency Contacts do you want to add?(Required)

Pick-up/Emergency Contact(s)

Please list below the people (other than the parents/guardians) who are authorized to pick up your child. (Authorized persons must be at least 13 years of age.) Indicate if these people could be contacted in an emergency when the parent(s) cannot be reached, and could be contacted to pick up your child if he or she is still at the Center after their scheduled hours and the parent(s) cannot be reached. If parents are not married, then only the parent(s) listed under #6 on the Child Application page as having legal custody is/are authorized to pick up the child, unless the other parent is listed below. State Licensing requires at least one emergency contact other than parents or guardians.

Pick-up/Emergency Contact Name (Legal)(Required)

First Last

Relationship to Child(Required)

Emergency Contact(Required)

YES

NO

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone Number(Required)

Work Phone Number

Pick-up/Emergency Contact Name (Legal)(Required)

First Last

Relationship to Child(Required)

Emergency Contact(Required)

YES

NO

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone Number(Required)

Work Phone Number

Pick-up/Emergency Contact Name (Legal)(Required)

First Last

Relationship to Child(Required)

Emergency Contact(Required)

YES

NO

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone Number(Required)

Work Phone Number

Pick-up/Emergency Contact Name (Legal)(Required)

First Last

Relationship to Child(Required)

Emergency Contact(Required)

YES

NO

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone Number(Required)

Work Phone Number

Signature