Vehicle Emergency Form

Vehicle Emergency Medical Information

Only for children transported by Camp Wieuca After School vehicles.
Child's Name
Date of Birth

MonthDayYear
Date
Address
Parent 1
Cell Phone
Work Phone
Parent 2
Cell Phone
Work Phone
Person to notify in an emergency and parents cannot be reached:
Name
Phone
Child's Doctor
Phone
Child's Allergies
Current prescribed medication
Child's special needs and conditions
In case of emergency, Camp Wieuca/Wieuca Road Bapist Church, will use Children's Healthcare of Atlanta at Scottish Rite, 1001 Johnson Ferry Road NE, Atlanta, GA 30342-1600.
In the event of an emergency involving my child, and if Camp Wieuca/Wieuca Road Baptist Church cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.
Child's Name
Signature (Parent/Guardian)

Clear
Witness By
Date

MonthDayYear
Date
Should be Empty:

Vehicle Emergency Medical Information