The Child's Nurturing Center, Inc.

2320 Old Westminster Pike

Finksburg, MD 21048-1729

(410) 833-7730

Consent to Contact Emergency Services

I/We, _____________________________________, give my/our permission to the staff of the infant
 
program or the director of The Child's Nurturing Center, Inc. to contact my/our child's pediatrician at the
 
following number:

___________________________________                          _____________________________

               Pediatrician's Name                                                               Telephone Number

in the event of an emergency when the parent or alternate cannot be reached.

___________________________________              __________________________________

                   Parent Signature                                                          Parent Signature

__________________

              Date