IB Emergency Information

Inner Beauty Program Inc. Emergency Information Sheet
Participant's Name (Last)
Participant's Name (First)
DOB
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full Name of Parent(s) or Guardian
Cell Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Emergency Contact: In the event that the primary guardian cannot be reached (Name) (Phone)
Emergency Contact Name
Emergency Contact Number
Please enter a valid phone number.
(Relationship)
Medical Information
Insurance Carrier
Policy No.
Family Doctor (Name)
(Phone)
Medical facts requiring special attention (Diabetes, Epilepsy, etc)
Allergies
Other Concerns
#1 List Medication
#1 Time to administer
#2 List Medication
#2 Time to administer
Do you object to our getting medical help for your child?

YesNo
May we take your child to the hospital before we call you?

YesNo
PARENT/GUARDIAN SIGNATURE

Clear
Parent Email
example@example.com
Date

MonthDayYear
Date
Should be Empty:

Medical Information