Emergency Information for John Smith
Child Summary
Name: John Smith
Birthdate:
Address: 12707 Blue Mountain Crescent, Maple Ridge, V3K 4T8
Start Date: 2025-07-02
End Date: 2026-04-01
Parents and Guardians
Name: Camille Ellison
Phone: (604) 655-6312
Name: Kyle Verge
Phone: (778) 384-5448
Emergency Contact
Name: Roberta Ellison
Phone: (604) 365-2110
Relation to Child: Grandmother
Doctor
Name: Erushka Naiker
Phone: (604) 939-8831
Dentist
Name: Sarah Lim
Phone: (604) 481-0222
Medical Number:
Immunization Status: Up-to-date
Allergy Information
Medication Information
It is the policy of this facility to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Our procedure is to call for an ambulance.
Please sign the consent below so that we can take the appropriate action on behalf of your child. Return the signed consent to the facility immediately. We will take this consent with us to the emergency centre.
I hereby give consent for my child to be taken to the nearest emergency centre to receive medical treatment when I cannot be contacted.
Date:
Parent/Guardian:
Witness: