Vehicle Emergency Medical Information

Vehicle Emergency Medical Information
Full name of child*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Child's Full Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
#1 Guardian's Name*

First NameLast Name
#1 Guardian's Cell Phone Number*
Please enter a valid phone number.
#1 Guardian's Work Phone Number*
Please enter a valid phone number.
#2 Guardian's Name

First NameLast Name
#2 Guardian's Cell Phone Number
Please enter a valid phone number.
#2 Guardian's Work Phone Number
Please enter a valid phone number.
Emergency Contact #1*

First NameLast Name
Emergency Contact #1 Relationship to Child*
Emergency Contact #1 Phone Number*
Please enter a valid phone number.
Emergency Contact #2*

First NameLast Name
Emergency Contact #2 Relationship to Child*
Emergency Contact #2 Phone Number*
Please enter a valid phone number.
Emergency Contact #3*

First NameLast Name
Emergency Contact #3 Relationship to Child*
Emergency Contact #3 Phone Number*
Please enter a valid phone number.
Child's Doctor*
Child's Doctor Phone Number*
Please enter a valid phone number.
Hospital Preference*
Child's Allergies
Current Prescribed Medications
Child's Special Needs & Conditions
In the event of an emergency involving my child and if Dragon Academy cannot get in contact with me, I authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child. By signing this form I am also agreeing should an emergency evacuation take place that Dragon Academy transport my child to a safe location (this is for all ages 6 wks to 12 yrs old)

In the event of an emergency Dragon Academy currently uses Piedmont Urgent Care located at 128 Panther Drive, Jefferson, GA 30549.

Center Emergency Procedure will be:

1. Contact Parents

2. Contact persons listed on this form as emergency contacts if parents cannot be reached.

3. Call emergency medical team if necessary (911 first if needed)

4. Transport child via emergency medical team to the nearest hospital.
Guardian Name*

First NameLast Name
Guardian Signature*

Clear
Date*

MonthDayYear
Should be Empty: