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718 Hogestown Road Mechanicsburg, PA 17050 ● 717.790.0770 ● Fax 717.795.1050  ceo@dumplinggang.org ● www.dumplinggang.org ● Apple Dumpling Group, Inc.

 Parent Contract   -   Mechanicsburg, PA

PARENTAL CONSENT & EMERGENCY INFORMATION

 

Child’s Last Name: ______________________ First Name: _________________________ DOB: _______________ Start Date: ___________________

Address: ________________________________ City: _______________________________ Zip Code: _____________ Program: _____________________

PARENT INFORMATION:

Mother’s Last Name: _____________________ First Name: __________________________

Address: ________________________________ City: _______________________________ Zip Code: ____________ Phone: ______________________

Work Name: ____________________________ Address: ____________________________ City: _________________ Zip Code: ___________________

Work Phone: ____________________________ Cellular Phone: _______________________ E-mail: _______________________________________________

Father’s Last Name: ______________________ First Name: __________________________

Address: ________________________________ City: _______________________________ Zip Code: ____________ Phone: ______________________

Work Name: ____________________________ Address: ____________________________ City: _________________ Zip Code: ___________________

Work Phone: ____________________________ Cellular Phone: _______________________ E-mail: _______________________________________________

PERSON TO BE CONTACTED IN AN EMERGENCY IF PARENTS ARE NOT AVAILABLE:

Last Name: _____________________________ First Name: __________________________ Relationship To Child: ___________________________________

Address: ________________________________ City: _______________________________ Zip Code: ____________ Phone: ______________________

Work Name: ____________________________ Address: ____________________________ City: _________________ Zip Code: ___________________

Work Phone: ____________________________ Cellular Phone: _______________________ E-mail: _______________________________________________

Last Name: _____________________________ First Name: __________________________ Relationship To Child: ___________________________________

Address: ________________________________ City: _______________________________ Zip Code: ____________ Phone: ______________________

Work Name: ____________________________ Address: ____________________________ City: _________________ Zip Code: ___________________

Work Phone: ____________________________ Cellular Phone: _______________________ E-mail: _______________________________________________

Last Name: _____________________________ First Name: __________________________ Relationship To Child: ___________________________________

Address: ________________________________ City: _______________________________ Zip Code: ____________ Phone: ______________________

Work Name: ____________________________ Address: ____________________________ City: _________________ Zip Code: ___________________

Work Phone: ____________________________ Cellular Phone: _______________________ E-mail: _______________________________________________

MEDICAL/DENTAL INFORMATION:

Physician’s Name: ______________________________________________________________

Address: ________________________________ City: _______________________________ Zip Code: ____________ Phone: ______________________

Dentist’s Name: ________________________________________________________________

Address: ________________________________ City: _______________________________ Zip Code: ____________ Phone: ______________________

Health Insurance Provider: _______________________________________________________ Policy Number: _______________________________________

Allergies: ______________________________________________________________________ Limitations: __________________________________________

(I/We) ___________________________________________ give our written consent for the administration of minor first aid (as required for admittance per DPW

regulations)

(I/We) ___________________________________________ give our written consent for the emergency medical treatment (as required for admittance per DPW

regulations)

(I/We) ___________________________________________ give our written consent for the emergency medical transportation (as required for admittance per

DPW regulations)

(I/We) ___________________________________________ give our written consent for the administration of prescription/non-prescription medication (current

instructions from physician MUST be provided)

(I/We) ___________________________________________ give our written consent for the walking excursions (off premises)

Director ___________________________________ Date __________ Parent: ____________________________________ Date: _________

Parent: ____________________________________ Date: _________

This form has been reviewed and up-dated ________ (6 months from date signed) Parent Initials: _______________________________ Date: _________

Revised – June 2008