Health and Emergency Authorization

Haywood Haven Health and Emergency Authorization

Complete all sections before your child's first day. This form is required for enrollment in any Haywood Haven program. One form covers up to four children in the same family.

Comments

This field is for validation purposes and should be left unchanged.

Parent(Required)

First Last

Phone(Required)

Enrollment Information

Tell us how many children you are enrolling so we can display the right sections.

Number of Children Being Enrolled(Required)

Physician Information

Provide the contact information for the children's primary care physician. If children have different physicians, list the primary physician here and note differences in the medical conditions section for each child.

Physician's Full Name(Required)

Practice or Clinic Name

Physician Phone Number(Required)

After-Hours or Emergency Line

Preferred Hospital for Emergency Transport

Child 1 - Child Information

Provide information for your first child.

Child 1 - Legal Name(Required)

First Last

Child 1 - Date of Birth(Required)

Child 1 - Age(Required)

Please enter a number from 3 to 18.

Child 1 - Grade (if applicable)

Child 1 - Program Enrolled(Required)

Kinder Prep (Ages 3-4, 8:30-12:30 PM)

Academic Partnership Program (K-12)

Child 1 - Known Allergies

List all known allergies including food, medication, environmental, and insect. Include the type of reaction for each. If your child has no known allergies, check the confirmation box below.

Child 1 - Known Allergies and Reactions(Required)

Child 1 - Epinephrine Auto-Injector on File

This child has a prescribed epinephrine auto-injector (EpiPen). I will provide a labeled, in-date EpiPen to Haywood Haven staff before my child's first day and will replace it whenever it expires or is used.

Child 1 - No Known Allergies Confirmation

I confirm this child has no known allergies at this time. I understand I am responsible for notifying Haywood Haven in writing immediately if this changes.

Child 1 - Medical Conditions

Include diagnosed conditions staff should be aware of.

Child 1 - Diagnosed Medical Conditions(Required)

Child 1 - Special Instructions or Staff Accommodations

Child 2 - Child Information

Provide information for this child.

Child 2 - Legal Name

First Last

Child 2 - Date of Birth

Child 2 - Age

Please enter a number from 3 to 18.

Child 2 - Grade (if applicable)

Child 2 - Program Enrolled

Kinder Prep (Ages 3-4, 8:30-12:30 PM)

Academic Partnership Program (K-12)

Child 2 - Known Allergies

List all known allergies including food, medication, environmental, and insect. Include the type of reaction for each. If your child has no known allergies, check the confirmation box below.

Child 2 - Known Allergies and Reactions

Child 2 - Epinephrine Auto-Injector on File

Child 2 - No Known Allergies Confirmation

I confirm this child has no known allergies at this time. I understand I am responsible for notifying Haywood Haven in writing immediately if this changes.

Child 2 - Medical Conditions

Include diagnosed conditions staff should be aware of.

Child 2 - Diagnosed Medical Conditions

Child 2 - Special Instructions or Staff Accommodations

Child 3 - Child Information

Provide information for this child.

Child 3 - Legal Name

First Last

Child 3 - Date of Birth

Child 3 - Age

Please enter a number from 3 to 18.

Child 2 - Grade (if applicable)

Child 3 - Program Enrolled

Kinder Prep (Ages 3-4, 8:30-12:30 PM)

Academic Partnership Program (K-12)

Child 3 - Known Allergies

List all known allergies including food, medication, environmental, and insect. Include the type of reaction for each. If your child has no known allergies, check the confirmation box below.

Child 3 - Known Allergies and Reactions

Child 3 - Epinephrine Auto-Injector on File

Child 3 - No Known Allergies Confirmation

I confirm this child has no known allergies at this time. I understand I am responsible for notifying Haywood Haven in writing immediately if this changes.

Child 3 - Medical Conditions

Include diagnosed conditions staff should be aware of.

Child 3 - Diagnosed Medical Conditions

Child 3 - Special Instructions or Staff Accommodations

Child 4 - Child Information

Provide information for this child.

Child 4 - Legal Name

First Last

Child 4 - Date of Birth

Child 4 - Age

Please enter a number from 3 to 18.

Child 4 - Grade (if applicable)

Child 4 - Program Enrolled

Kinder Prep (Ages 3-4, 8:30-12:30 PM)

Academic Partnership Program (K-12)

Child 4 - Known Allergies

List all known allergies including food, medication, environmental, and insect. Include the type of reaction for each. If your child has no known allergies, check the confirmation box below.

Child 4 - Known Allergies and Reactions

Child 4 - Epinephrine Auto-Injector on File

Child 4 - No Known Allergies Confirmation

I confirm this child has no known allergies at this time. I understand I am responsible for notifying Haywood Haven in writing immediately if this changes.

Child 4 - Medical Conditions

Include diagnosed conditions staff should be aware of.

Child 4 - Diagnosed Medical Conditions

Child 4 - Special Instructions or Staff Accommodations

Emergency Contact 1 - Primary

This contact must be reachable by phone during all program hours.

Emergency Contact 1 - Full Name(Required)

First Last

Emergency Contact 1 - Relationship to Child(Required)

Emergency Contact 1 Phone(Required)

Emergency Contact 1 - This person is authorized to pick up my child.(Required)

Yes

Emergency Contact 2 - Secondary

A second contact is required. This person should be reachable if the primary contact cannot be reached.

Emergency Contact 2 - Full Name(Required)

First Last

Emergency Contact 2 - Relationship to Child(Required)

Emergency Contact 2 Phone(Required)

Emergency Contact 2 - This person is authorized to pick up my child.(Required)

Yes

Individuals NOT Permitted to Pick Up

Authorization for Emergency Care and First Aid

Read each statement carefully. Check each box to indicate your consent. Your signature below confirms all authorizations and applies to all children enrolled on this form.

Emergency Services Authorization(Required)

I authorize Haywood Haven staff to call 911 and request emergency medical services on behalf of my child or children if staff determine that an emergency exists. I understand that I will be contacted as soon as practicable after emergency services are called.

Basic First Aid Authorization(Required)

I authorize Haywood Haven staff to administer basic first aid including wound cleaning, bandaging, application of ice or cold compress, and positioning for comfort while emergency contacts are reached.

Epinephrine Auto-Injector Authorization

I authorize Haywood Haven staff to administer a prescribed epinephrine auto-injector on file for my child in the event of a suspected anaphylactic reaction, without waiting for my arrival or verbal confirmation. This authorization applies only to a device I have personally provided and labeled for my child.

Emergency Transport Authorization(Required)

I authorize emergency medical personnel to transport my child or children to the nearest appropriate medical facility if they determine transport is necessary. I accept financial responsibility for any costs associated with emergency transport and treatment.

Incident Notification Acknowledgment(Required)

I understand that Haywood Haven staff will notify me of any injury, illness, or medical incident involving my child or children as promptly as circumstances allow, and that a written incident report will be provided for any event requiring first aid or emergency services.

Haywood Haven staff are not licensed medical professionals. First aid administration is limited to basic care as described above. Haywood Haven does not administer prescription medications of any kind. The only exception is a parent-provided, prescribed epinephrine auto-injector for a child with a documented anaphylactic allergy and a signed authorization on file. Staff will administer an EpiPen only in the event of a suspected anaphylactic reaction.

Parent or Guardian Signature

By completing this section, you confirm that all information provided is accurate and complete to the best of your knowledge. This signature applies to all children enrolled on this form. You accept responsibility for notifying Haywood Haven in writing of any changes to this information within five business days of the change.

Parent or Guardian Printed Name(Required)

First Last

Signature - Type Full Legal Name to Sign(Required)

Typing your full legal name in this field constitutes your electronic signature under the Uniform Electronic Transactions Act.

Date(Required)

Parent or Guardian Email Address(Required)

A confirmation of this submission will be sent to this address. Keep it on file for your records.

Haywood Haven | Learning Havens Incorporated | 1400 Old Clyde Road, Clyde, NC | This authorization is required annually and must be updated in writing whenever any information changes.