Emergency Contact Form printable pdf download

Poughkeepsie Tennis Club Summer Camp

Emergency Contact Form

Child’s Name_____________________________ Nickname___________

Address______________________________________________________

Father’s Name________________________________________________

Address_____________________________________________________

Work Phone_______________________ Cell Phone_________________

Email_____________________________ Home Phone_______________

The best way to contact during camp hours: _______________________

Mother’s Name_______________________________________________

Address_____________________________________________________

Work Phone_______________________ Cell Phone_________________

Email_____________________________ Home Phone_______________

The best way to contact during camp hours:_______________________

Pediatrician___________________________Phone__________________

Dentist_______________________________ Phone__________________

In case of emergency, if parents cannot be reached, contact:

Name_______________________________ Phone #________________

Relationship to Child:_________________________________________

Optional Second Contact:

Name_______________________________ Phone #________________

Relationship to Child:_________________________________________

Does your child have any allergies (foods, medicine, bees etc)?

Yes___ No___ If yes, please explain:____________________________

___________________________________________________________

Is there any other helpful information you would like us to know about

your child in case of an emergency? ______________________________

Insurance Carrier/Group Number/Information_____________________

_____________________________________________________________

Parent Signature_______________ Print Name_____________

Emergency Contact Form