Endless Innovation Academy

2310 S. 12th St, Allentown – 18103

Email : endlessinnovationacademy@gmail.com

Phone : (610) 841-9997

EIA Emergency Contact and Parental Consent Form

Emergency Contact / Parental Consent Form | Endless Innovation Academy

Endless Innovation Academy

Emergency Contact / Parental Consent Form

Please complete one form per child. This information is required before your child’s first day of care and should be updated any time contact, medical, or consent information changes. Fields marked * are required.
1Child Information
2Parent / Guardian Information

List each parent or legal guardian who has permission to make decisions for this child. Guardian 2 is optional.

Parent / Guardian 1
Parent / Guardian 2
3Emergency Contacts

People (other than parents/guardians) who may be contacted, and who may be relied on, while your child is in our care.

Emergency Contact 1
Emergency Contact 2
Person(s) to Whom Child May Be Released
4Medical Information
Physician / Medical Care Provider
Insurance
Health Details
5Parental Consent
Your parent/guardian signature at the end of this form is required to indicate consent for each item below. Please select Yes or No for every item.
Walks and Trips
Swimming
Transportation by the Facility
Wading
Obtaining Emergency Medical Care
Administration of Minor First-Aid Procedures
Periodic Review
6Signatures

Typing your full legal name below and submitting this form constitutes your electronic signature, consistent with the paper form’s requirement of a parent/guardian signature for each consent item above.

Signature of Parent or Guardian 1

Signature of Parent or Guardian 2 (optional)

Based on PA Code 55 Chapters 3270/3280/3290 § .124(a)(b), .181 & .182 — Form CY 867 (10/22). Digitized for Endless Innovation Academy.