Emergency Contact and Medical Information Form

I hereby authorize the person above to pick up the child(ren) listed on this form. I understand that the authorized person must present valid government-issued identification before the child(ren) will be released.

Only I or the authorized pickup person named in this section has permission to pick up the child(ren).

I hereby give permission to The Children's Cottage Society as follows:

1. To administer first aid and medication as prescribed, to the above-named child(ren). In the event that further treatment is necessary, every effort will be made to contact the parent/guardian or emergency contacts. If staff are unable to contact any of the above and in case of a medical emergency, I hereby grant permission for my child(ren) to be transported by ambulance to an appropriate medical facility, if necessary. I understand that any expenses that are incurred for an ambulance or further medical treatment will be the responsibility of the parent/guardian.

2. I acknowledge that if the safety protocols and rules set out by The Children’s Cottage Society are not followed by my child(ren), I will be phoned and expected to pick them up immediately.