Emergency Contact Form - The Children'S Circle printable pdf download

THE CHILDREN’S CIRCLE AT MYERS PARK UNITED METHODIST CHURCH

EMERGENCY CONTACT FORM

Child’s Name:_____________________________________________Date of Birth:_______________________

Legal Guardian #1 Name:_____________________________________________________________________

Phone Numbers for Home:_____________________Work:___________________Cell:___________________

Legal Guardian #2 Name:_____________________________________________________________________

Phone Numbers for Home:_____________________Work:___________________Cell:___________________

Emergency Contacts (to whom child may be released if legal guardian is unavailable. Continue on back if

needed.)

Name:____________________________________________________________________________________

Phone Numbers for Home:_____________________Work:___________________Cell:___________________

Name:____________________________________________________________________________________

Phone Numbers for Home:_____________________Work:___________________Cell:___________________

Child’s Usual Source of Medical Care

Name:____________________________________________________________________________________

Address:___________________________________________________________________________________

Phone Number:_____________________________________________________________________________

Child’s Health Insurance

Name of Insurance Plan:_______________________________________ID#____________________________

Subscriber’s Name (on insurance card):__________________________________________________________

Special Conditions, Allergies, or Medical Information for Emergency Situations:

Parent/Legal Guardian Consent and Agreement for Emergencies:

As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and if necessary, be

transported to receive emergency care. I understand that I will be responsible for all charges not covered by

insurance. I give consent for the emergency contact person listed above to act on my behalf until I am

available. I agree to review and update this information whenever a change occurs.

Parent/Legal Guardian’s Signature #1___________________________________ Date:__________________

Parent/Legal Guardian’s Signature #2___________________________________ Date:__________________

Emergency Contact Form - The Children'S Circle