Fillable Emergency Contact Form printable pdf download

Emergency Contact Form

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Tahoe City Public Utility District

PO Box 5249, 221 Fairway Drive

Tahoe City, CA 96145 (530) 583-3440 FAX (530) 583-1475

EMERGENCY CONTACT FORM

Date: ___________________

Child’s Last Name:

First Name:

DOB

Child’s Last Name:

First Name:

DOB

Child’s Last Name:

First Name:

DOB

IN CASE OF EMERGENCY CONTACT:

Name & Relationship

Street Address:

City:

State:

Zip Code:

Telephone #

Alternate Phone #

Name & Relationship

Street Address:

City:

State:

Zip Code:

Telephone #

Alternate Phone #

MEDICAL INFORMATION

Is your child (ren) allergic to anything? If yes, list all allergies and use of inhaler, EpiPen, etc.:

______________________________________________________________________________________________

Does your child (ren) take any medication we should be aware of? If yes, list all medications:

______________________________________________________________________________________________

Does your child (ren) have any medical/mobility/mental health concerns of which we should be aware?

If yes, please list:

______________________________________________________________________________________________

If your child (ren) has food allergies please list the kinds of snacks that can be given:

______________________________________________________________________________________________

t:\district working\parks & recreation\forms\master forms\rap forms\emergency contact form 2014.docRev. Date: 9/12/14

Emergency Contact Form

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