Child'S General Information And Emergency Contact Form

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Medical and Emergency Contact Form
(please fill out one form for each registrant.)
Child’s General Information
Name: ___________________________________________________________
Birthday: _____________________________Age: ________________________
Doctor’s Name: ___________________________________ Doctor’s Phone #:_____________________
Does your child have developmental and/or physical challenges?(If yes, please explain)
Doe your child have allergies?
Is your child taking any mediation? (if yes, please specify)
Parent/Guardian Information
Full Name(s): ________________________________________________________________________
Street Name & Number: _____________________________ City: _____________________________
Postal Code: ___________________________ Home Phone#: _________________________________
Work Phone #: _________________________ Cell Phone#: ___________________________________
E-mail Address: ______________________________________________________________________
Emergency Contacts & Information
Primary Emergency Contact Name: ___________________________ Phone #:____________________
Secondary Emergency Contact Name: _________________________ Phone #____________________
I give permission for my child___________________________ to be taken to the hospital in case of an
emergency, and consent to emergency treatment until the time of my arrival at the hospital. I understand
that every effort will be made to contact me in the event that such an emergency takes place.
Signature of Parent/Guardian
Date Signed
Delaware Children’s Museum • 550 Justison St, Wilmington, DE. 19801 • (302) 654-2340


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