Child Medical History & Emergency Contact Form
Share your child’s medical details, list two emergency contacts, and confirm permission for social media story posting.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child have any allergies?
*
Food allergies
Medication allergies
Other allergies
No known allergies
Please provide details of any allergies (if applicable)
Does your child have any medical conditions?
*
Asthma
Diabetes
Seizure disorder
Heart condition
No known conditions
Other
Please provide details of any medical conditions (if applicable)
Is your child currently taking any medications?
*
Yes
No
If yes, please list all medications and dosages
Has your child had any recent broken bones or injuries that we should know about?
*
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contact #1 Full Name
*
First Name
Last Name
Emergency Contact #1 Relationship to Child
*
Emergency Contact #1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 Full Name
*
First Name
Last Name
Emergency Contact #2 Relationship to Child
*
Emergency Contact #2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you approve us posting your child on our Instagram and Facebook stories?
*
Yes, I approve
No, I do not approve
Submit
Should be Empty: