Parental Consent And Release Of Liability Agreement Page 3
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5Emergency Information Form
Please complete this form in its entirety. This information will be helpful in the unlikely event of an
accident or sudden illness.
Participant’s Name: _________________________________________ Phone: _____________________
Participant’s Address: __________________________________________________________________
Date of Birth: ______________________________________________ Email: _____________________
Name of Primary Care Physician: ______________________________ Contact #: __________________
Emergency Contact Information
Person’s to be contacted in case of an emergency:
Name: ____________________________________________________ Relationship: _______________
Address: _____________________________________________________________________________
Cell Phone: _________________ Home Phone: _________________ Work Phone: _________________
Name: ____________________________________________________ Relationship: _______________
Address: _____________________________________________________________________________
Cell Phone: _________________ Home Phone: _________________ Work Phone: _________________
Name: ____________________________________________________ Relationship: _______________
Address: _____________________________________________________________________________
Cell Phone: _________________ Home Phone: _________________ Work Phone: _________________
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