Emergency Contact Form

Emergency Contact Form

Adventure Club
Student Information
Name of Child*
Child Date of Birth*

MonthDayYear
Date
Child Gender*
Grade at time signing up*
Attending School*
Guardian Contact
Primary Contact Name*
Primary Contact Email*
example@example.com
Primary Contact Address*

Parent Address

Street Address Line 2

CityState / Province

Zip
Primary Contact Cell Phone*
Primary Contact Work Phone*
Secondary Contact Name*
Secondary Contact Email*
example@example.com
Secondary Contact Address*

Parent Address

Street Address Line 2

CityState / Province

Zip
Secondary Contact Cell Phone Number*
Secondary Contact Work Phone*
Emergency Contacts
I authorize the following individuals to collect my child from Adventure Club in case of emergency or if I cannot be contacted:
First Emergency Contact Name*
First Emergency Contact Phone Number*
Second Emergency Contact Name*
Second Emergency Contact Phone Number*
Health Conditions
Are there any allergies, health conditions or physical limitations that we need to be aware of?
By signing (typing name in) the form, you are stating that you confirm the information provided is accurate to the best of your knowledge.
Todays Date *

MonthDayYear
Date
Guardian/Parent Signature*
Should be Empty:

Guardian Contact