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Emergency Health Care Form Child:_________________________________________________ DOB:____________________ Insurance_____________________ Doctor:___________________Hospital_______________________ If the event your child needs emergency medical attention the following steps will be taken: 1. Call 911 2. Call parents 3. Call Doctor(if need be) I, Velvet xxxxxxxxxxx, will perform the said steps. However, I will not leave My Little Playland. I have to stay with the other children and be home for my children. This form is in addition to the Medical Power of Attorney Form. Provider Signature: X____________________________________________Date:____________ Parent/Guardian Signatures: X____________________________________________Date:____________ X____________________________________________Date:____________
