Shoemakersville Park Program Emergency/contact Information Form

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Shoemakersville Park Program
Emergency/Contact Information Form 2016
Child’s Name: __________________________________________
Age: _________________________________________________
Date of Birth: __________________________________________
(Child must be 8years old or accompanied by an adult at all times)
Address: ______________________________________________
Parent E-mail:________________________________________________
In Case of Emergency Contact:
First Contact: ___________________________________________
Phone Number: (H) ________________________(C) _____________________
Alternate Contact: _______________________________________
Phone Number: (H) _________________________ (C) ____________________
Family Doctor: __________________________________________
Hospital Preferred: _______________________________________
Known Allergies: ________________________________________
List any Medical Problems: ________________________________
List any Current Medications: _______________________________
We do not administer medications!
I hereby certify that to the best of my knowledge all information contained herein is true
and correct.
Parent/Guardian signature: ____________________________________
Date: _____________________________________________
(KEEP ON FILE)

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