Pre-K Counts/Headstart Program Enrollment

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EMERGENCY CONTACT PARENTAL CONSENT FORM

55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182

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EMERGENCY CONTACT PERSON(S)
NAME
TELEPHONE NUMBER WHEN CHILD IS IN CARE

PERSON(S) TO WHOM CHILD MAY BE RELEASED
NAME
ADDRESS
TELEPHONE NUMBER WHEN CHILD IS IN CARE

PARENTS SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

PERIODIC REVIEW
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