Emergency Contact Information printable pdf download

Emergency Contact Information

EMERGENCY CONTACT/PARENTAL CONSENT FORM

CHILD’S NAME

BIRTHDATE

ADDRESS

FATHER’S NAME/LEGAL GUARDIAN

HOME TELEPHONE NUMBER

ADDRESS

CELULAR PHONE NUMBER

BUSINESS NAME

WORK NUMBER

MOTHER’S NAME/LEGAL GUARDIAN

HOME TELPHONE NUMBER

ADDRESS

CELLULAR PHONE NUMBER

BUSINESS NAME

WORK NUMBER

EMERGENCY CONTACT PERSON

PHONE NUMBER

ADDITIONAL PERSON(S) TO WHOM CHILD MAY BE RELEASED

PHONE NUMBER

NAME OF CHILD’S PHYSICIAN/MEDICAL CARE PROVIDER

PHONE NUMBER

SPECIAL DISABILITIES (IF ANY)

ALLERGIES (INCLUDING MEDICATION REACTIONS)

MEDICAL/DIETARY INFO. NECESSARY IN EMERGENCY

MEDICATIONS/SPECIAL CONDITIONS

SITUATION

ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD

HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS

POLICY NUMBER (REQUIRED)

PARENT SIGNATURE REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE

ADMIN. OF MINOR FIRST AID PROCEDURES

WALKS AND TRIPS

SWIMMING

TRANSPORTATION BY FACILITY

WADING

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SIGNATURE OF PARENT OR GUARDIAN

DATE

Emergency Contact Information