Emergency Contact Form Page 3
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4EMERGENCY CONTACT FORM
OUT-OF-TOWN CONTACT (in case local contacts cannot be reached)
First and Last Name:
Relationship to Child:
Work Address:
Home Address:
Work Phone:
Home Phone:
Cell:
E-mail:
Twitter:
Facebook:
MEDICAL OR SPECIAL CARE INFORMATION
My child has the following medical conditions and allergies:
My child takes the following prescription medications:
My child needs the following medical treatment or care:
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