Emergency and Identification Form
Child's Name
Child's Date of Birth
Parent/Guardian 1 Name
Phone Number
email
Address
Parent/Guardian 2 Name
Phone Number
email
Address (if different)
Preferred contact in case of emergency. Name, phone, email
Additional persons who may be called in case of emergency. Name, phone, relationship.
Physician or Dentist to be called in case of emergency. Name
Address
Phone
Medical Plan Information
If physician cannot be reached please
Call Emergency Hospital
Other
if Other, please explain
Medical history, allergies, or injuries that may affect child's participation in program
Submit
Should be Empty: