Medical Consent & Emergency Contact Form
Child’s Last Name: ____________________ First: ___________________
DOB ____/_____/_____ SEX ________
Additional Child’s Last Name: ____________________ First: ___________________
DOB ____/_____/_____ SEX ________
Additional Child’s Last Name: ____________________ First: ___________________
DOB ____/_____/_____ SEX ________
Home Address: ______________________________________
___________________________________________________
City: ___________________________ State: ______ Zip Code: _____________
Email: _____________________________________________
Please Check Primary Contact
[ ] Contact Parent Name: ________________________________
Daytime# Cell: ___________________________
[ ] Contact Parent Name: ________________________________
Daytime# Cell: ___________________________
Medical History
Please list any medical conditions, allergies, learning disabilities, etc. that we should be aware of or that
would help us when working with your child:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family Doctor’s Name: _____________________________________
Phone #: ______________________________
Please sign & date below