Medical Consent & Emergency Contact Form

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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 

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