Release of Information Form

Child Emergency Information & Parental Consent Form

Keeping children safe, informed, and protected.

Please complete this form to provide essential information about your child and authorize our organization to share relevant information with emergency responders, healthcare professionals, and appropriate authorities when necessary to protect your child’s health, safety, and well-being.

Child's Information

Date of Birth:

Gender (optional):

Male Female

Home Address

City

State

ZIP Code

Parent/Guardian's Full Name

Relationship to Child

Primary Phone Number

Secondary Phone Number

Email Address

Home Address (if different)

Please provide at least one additional emergency contact who may be reached if the parent or legal guardian is unavailable.

Emergency Contact 1

Full Name

Relationship to Child

Phone Number

Emergency Contact 2

Full Name

Relationship to Child

Phone Number

Please provide any information that may be important in an emergency. Share only information necessary for the child's safety and care.

Known Allergies

Existing Medical Conditions (if applicable):

Current Medications (if relevant)

Other Important Medical Information

Preferred Hospital or Healthcare Provider (optional)

I, the undersigned parent or legal guardian of the child identified above, authorize KidzWithHope, including its authorized staff and representatives, to disclose relevant information about my child to emergency medical personnel, healthcare providers, emergency responders, and appropriate authorities when reasonably necessary to respond to an emergency, protect my child's health or safety, or comply with applicable legal requirements. This authorization may include, when relevant:

• The child's name, age, and identifying information.

• Emergency contact information for parents, guardians, or designated contacts.

• Relevant medical information, including known allergies, medical conditions, and medications.

• Other information reasonably necessary to facilitate emergency assistance or protect the child's immediate safety.

I understand and acknowledge that:

1. Information will be shared for emergency response, medical care, child safety, or legally authorized purposes, as applicable.

2. The organization will make reasonable efforts to limit disclosure to information relevant to the situation, subject to applicable law.

3. This authorization does not replace any separate consent required by law or authorize unrelated use or disclosure of my child's information.

4. I may contact the organization to ask questions, update information, or request withdrawal of this authorization, subject to applicable legal obligations and any limitations on withdrawal once information has been disclosed.

5. I am the child's parent or legal guardian and have the authority to provide this consent.

Please read the authorization above carefully before providing your consent.

I authorize the organization to share my child's relevant information with emergency responders, medical personnel, healthcare providers, and appropriate authorities as described in this form.

I confirm that the information provided is accurate and complete to the best of my knowledge.

Parent/Guardian's Full Name

Date

Organization Use Only

Form Received By

Date Received

Last Updated

Privacy Notice: The organization will handle the information collected through this form in accordance with its privacy and safeguarding policies and applicable law. Access should be limited to authorized personnel with a legitimate need to know. This form should be reviewed periodically to ensure the information remains accurate.
Thank you for helping us keep your child safe.