MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
Page 1 of 2
OCC 1214 (Revised 01/2022) - All previous editions are obsolete.
CACFP Enrollment: Yes:___ No:____
Meals your child will receive while in care:
BK___ LN___SU___ AM Snk___ PM Snk___ Evng Snk___
EMERGENCY FORM
INSTRUCTIONS TO PARENTS:
(1) Complete all items on this side of the form. Sign and date where indicated. Please mark “N/A” if an item is not applicable.
(2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s
health practitioner review that information.
NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.
Child’s Name ___________________________________________________________________________ Birth Date ___________________________
Last First
Enrollment Date ______________________________ Hours & Days of Expected Attendance ____________________________________
Child’s Home Address __________________________________________________________________________________________________________
Street/Apt. # Cit
y
State Zip Code
Parent/Guardian Name(s)
Relationship
Contact Information
Email:
C:
H:
W:
Employer:
Email:
C:
H:
W:
Employer:
Name of Person Authorized to Pick up Child (daily) ___________________________________________________________________________________
Last First Relationship to Child
Address _____________________________________________________________________________________________________________________
Street/Apt. # City State Zip Code
Any Changes/Additional Information_____________________________________________________________________________________________
__________________________________________________________________________________________________________________________
ANNUAL UPDATES _____________________ ______________________ ______________________ ______________________
(Initials/Date) (Initials/Date) (Initials/Date) (Initials/Date)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:
1. Name _____________________________________________________________ Telephone (H) _________________ (W) __________________
Last First
Address _________________________________________________________________________________________________________________
Street/Apt. # City State Zip Code
2. Name ______________________________________________________________ Telephone (H) _________________ (W) ___________________
Last F
i
r
s
t
Address _________________________________________________________________________________________________________________
Street/Apt. # City State Zip Code
3. Name ______________________________________________________________ Telephone (H) _________________ (W) ___________________
Last First
Address _________________________________________________________________________________________________________________
Street/Apt. # City State Zip Code
Child’s Physician or Source of Health Care ___________________________________________________ Telephone ____________________________
Address _____________________________________________________________________________________________________________________
Street/Apt. # City State Zip Code
In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature
authorizes the responsible person at the child care facility to have your child transported to that hospital.
Signature of Parent/Guardian ____________________________________________________________Date ___________________________________
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
Page 2 of 2
OCC 1214 (Revised 01/2022) - All previous editions are obsolete.
INSTRUCTIONS TO PARENT/GUARDIAN:
(1) Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical
care.
(2) If necessary, have your child’s health practitioner review the information you provide below and sign and date where
indicated.
Child’s Name: ___________________________________________________ Date of Birth: _______________________
Medical Condition(s): _________________________________________________________________________________
____________________________________________________________________________________________________________________________
Medications currently being taken by your child: ____________________________________________________________
____________________________________________________________________________________________________________________________
Date of your child’s last tetanus shot: _____________________________________________________________________
Allergies/Reactions: ___________________________________________________________________________________
____________________________________________________________________________________________________________________________
EMERGENCY MEDICAL INSTRUCTIONS:
(1) Signs/symptoms to look for: _________________________________________________________________________
____________________________________________________________________________________________________________________________
(2) If signs/symptoms appear, do this: ____________________________________________________________________
(3) To prevent incidents: ______________________________________________________________________________
____________________________________________________________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
OTHER SPECIAL MEDICAL PROCEDURES THAT MAY BE NEEDED: __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
COMMENTS: ________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Note to Health Practitioner:
If you have reviewed the above information, please complete the following:
________________________________________________ ____________________________________
Name of Health Practitioner Date
_________________________________________________ (_____) ______________________________
Signature of Health Practitioner Telephone Number
