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Bellingham Cooperative School EMERGENCY CONTACT INFORMATION AND CONSENT FORM Child’s Name​
: ___________________ Birth Date: __/__/__ Gender Pronouns: ___________ Address: ___________________________________________________________________ Parent/Guardian #1 ​
Name​
: ____________________ ​
Telephone​
: Home _________________ Work _________________ Cell _________________ Text ok? yes no Email: _____________________________________________________________________ Parent/Guardian #2 ​
Name​
: ____________________ ​
Telephone​
: Home _________________ Work _________________ Cell _________________ Text ok? yes no Email: _____________________________________________________________________ EMERGENCY CONTACTS (to whom child may be released if guardian is unavailable) Name​
#1: ______________________ Relationship to child: ______________________ Telephone​
: Home _______________ Work _________________ Cell _________________ Text ok? yes no Name​
#2: ______________________ Relationship to child: ______________________ Telephone​
: Home _______________ Work _________________ Cell _________________ Text ok? yes no People who may pick up my child from BCS: ______________________________________ _________________________________________________________________________ CHILD’S PREFERRED SOURCES OF MEDICAL CARE Physician’s Name: ________________________ Telephone: _________________________ Dentist’s Name: __________________________ Telephone: _________________________ (Parents are responsible for all emergency transportation charges) CHILD’S HEALTH INSURANCE Insurance Plan: _____________________________________________________________ ID # _________________________ Subscriber’s Name): ____________________________ SPECIAL CONDITIONS, DISABILITIES: ____________________________________________________________________________
________________________________________________________________________ ALLERGIES: _______________________________________________________________ SENSITIVITIES: _____________________________________________________________ PARENT/GUARDIAN CONSENT AND AGREEMENT FOR EMERGENCIES: As parent/guardian, I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive emergency care. I will be responsible for all charges not covered by insurance. I consent for the emergency contact person listed above to ACT ON MY BEHALF Bellingham Cooperative School 360.220.7403 www.bellinghamcooperativeschool.com info@bellinghamcooperativeschool.com physical address mailing address 1207 Ellsworth Street, Bellingham, WA 98225 PO Box 957, Bellingham, WA 98227­0957 until I am available. I agree to review and update this information whenever a change occurs and at least every year. Parent/Guardian Signature: _________________________ Date: __________________ Parent/Guardian Signature: _________________________ Date: __________________ Bellingham Cooperative School 360.220.7403 www.bellinghamcooperativeschool.com info@bellinghamcooperativeschool.com physical address mailing address 1207 Ellsworth Street, Bellingham, WA 98225 PO Box 957, Bellingham, WA 98227­0957