2024 ICE FORM

Participant Name*

Date of Birth*

Date

Mailing Address

Hemlock Farms Street Address*

Parent or LEGAL Guardian*

Best Phone Number to be reached*

Format: (000) 000-0000.

Yes

Temporary Care Giver

Relation to Participant

Best Phone Number to be reached

Format: (000) 000-0000.

Yes

I, Name of Parent/Guardian , parent or legal guardian of Participating Child, give permissions for Temporary Caregiver , temporary caregiver to my child, consent to authorize treatment or refuse treatment for my child on my behalf.

1st Emergency Contact*

Best Phone Number to be reached*

Format: (000) 000-0000.

2nd Emergency Contact*

Best Phone Number to be reached*

Format: (000) 000-0000.

Please list all individuals who are authorized to pick up the child:*

Please provide information on any health history, health issues, and all medical information pertinent to participation in the program enrolled. List all & describe: *

Does the participant have any allergies? List all & describe:*

List all medication the participant takes and the reason for the medication. All medications should be documented in the event the participant requires medical care. *

PLEASE NOTE: If, at any time during a scheduled program, the participant appears to have a contagious or communicable illness, they may not attend the program until cleared by a medical professional. If your failure to disclose the participant's special needs or health issues jeopardizes the safety of the participant, other program participants or HFCA Staff, the HFCA will not be held liable. In the event of any EMERGENCY, I authorize Hemlock Farms Community Association staff to secure emergency medical treatment by certified responders, emergency medical personnel and/or in a local, licensed hospital, for any treatment deemed necessary for the participant's immediate care. If parent/legal guardian or temporary caregiver cannot be reached, standard EMS protocols will be followed, which will include transportation to a local hospital for further evaluation and medical treatment. I agree that I will be responsible for payment of any and all medical services rendered, the HFCA will not be responsible for any fees associated with any medical care or services rendered.

PARENT OR LEGAL GUARDIAN Signature*

Date*

Date

Email*

example@example.com

I.C.E. Form