Emergency Contact/Parental Consent Form

Please complete and submit this form by August 1, 2019

At the bottom of the page you have the option to SUBMIT or SAVE AND CONTINUE LATER.

ECDC Emergency Contact/Parental Consent Form 2019-2020

55 PA CODE
  • Select + to add another row.
    NameTelephone Number When Child is in Care 
    Add a new row
  • Select + to add another row.
    NameStreet AddressZip CodeTelephone Number When Child is in Care 
    Add a new row
  • Parent Signature is Required for Each Item Below to Indicate Parental Consent