Gan Elohim Emergency Card

This emergency card information is for the educator’s first aid kit. The educator(s) must take first aid materials when leaving the child care premises. 

Please submit one form per child attending.

Instructions to Reach Parent(s)/Guardian(s) to be contacted FIRST

Emergency Medical Treatment
Contact Information for Physician or Health Care Professional

Emergency Contacts (NON-PARENT)
The following (NON-PARENT) people are authorized to pick up my child. Please list LOCAL people for these emergency contacts.

Allergy Information

Please note: We require two (2) Epi-Pens per child as prescribed by the pediatrician along with a signed Allergy Action Plan. See a sample Allergy Action Plan.
Medical Insurance Information

Electronic Signature