Power Of Attorney Form For Care Of Minor Nj Page 5

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INFORMATION-SHEET  
Complete   o ne   f or   E ach   C hild  
 
Parent   _ ________________________________  
 
Signed  
 
Date:   _ _____________________  
 
Home   P hone   _ ________________         W ork   P hone   _ _______________  
 
Other   p hone   n umber   _ _________________________  
 
Other   E mergency   C ontact   _ __________________     P hone   _ __________  
 
Family   D octor   _ ___________________         P hone     _ ________________  
 
Insurance   C o.   _ _________________                 I f   N one   P lease   C heck     ( __)  
 
Insurance   P olicy   N ame   a nd   #   _ _______________________________  
 
Known   M edical   C onditions  
 
________________________________________________________  
 
________________________________________________________  
 
   
 
Medications?   _ ____________________________________________  
 
Allergies?   _ _______________________________________________  
 
Last   T etanus   I mmunization?   _ _________________________________  
 
Will   Y ou   A llow   B lood   T ransfusions?   Y es   ( __)       N o   ( __)  
 
Other   _ __________________________________________________  
 

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