Lmergency Contact and Med|ca| Informat|on for a Ch||d

M l
Chlld's name uaLe of 8lrLh Sex

arenL's/ Cuardlan's name arenL's/ Cuardlan's name
( ) ( ) ( ) ( )
Pome hone Work hone Pome hone Work hone

Address Address

ClLy S1 Zl Code ClLy S1 Zl Code

A|ternat|ve Lmergency Contacts


rlmary Lmergency ConLacL Secondary Lmergency ConLacL
( ) ( ) ( ) ( )
Pome hone Work hone Pome hone Work hone

Address Address

ClLy S1 Zl Code ClLy S1 Zl Code

Med|ca| Informat|on


PosplLal/ Cllnlc reference

hyslclan's name hone number

lnsurance Company ollcy number

Allergles/ Speclal PealLh ConslderaLlons

l auLhorlze all medlcal and surglcal LreaLmenL xray laboraLory anesLhesla and oLher medlcal/ surglcal
procedures as may be performed or prescrlbed by Lhe aLLendlng physlclan and/or paramedlcs for my chlld
and walve my rlghL Lo lnformed consenL of LreaLmenL 1hls walve applles only ln Lhe evenL LhaL nelLher
parenL/ guardlan can be reached ln Lhe case of an emergency

arenL's/ Cuardlan's SlgnaLure uaLe

l glve permlsslon for my chlld Lo go on fleld Lrlps l release (CrganlzaLlon) and lndlvldual from llablllLy ln
case off accldenL durlng acLlvlLles relaLed Lo (CrganlzaLlon) as long as normal safeLy procedures have
been Laken


arenL's/ Cuardlan's SlgnaLure uaLe

WlLness SlgnaLure uaLe