Computers for Youth Foundation, Inc.

(“CFY”) Student Software Team (“SST”) Emergency Contact and Medical Information for a Child/ Contacto de emergencia y información medico
M Child’s Name/Nombre de hijo/a Date of Birth/Fecha de nacimiento F Sex/Sex o

Parent’s/Guardian’s Name/Nombre de pariente o guardian ([ ]) Home Phone/Número de casa Address/Dirección City/Ciudad, ST/Estado ZIP Code/Codigo postal ([ ]) Work Phone/Número de trabajo

Parent’s/Guardian’s Name/Nombre de pariente o guardian ([ ]) Home Phone/Número de casa Address/Dirección City/Ciudad, ST/Estado ZIP Code/Codigo postal ([ ]) Work Phone/Número de trabajo

Alternative Emergency Contacts/Contacto de emergencia secundario/a

Primary Emergency Contact/Contacto de emergencia primario/a ([ ]) Home Phone/Número de casa Address/Dirección City/Ciudad, ST/Estado ZIP Code/Codigo postal Relationship to Child/Relación al niño/a ([ ]) Work Phone/Número de trabajo

Secondary Emergency Contact/ Contacto de emergencia secundario/a ([ ]) Home Phone/Número de casa Address/Dirección City/Ciudad, ST/Estado ZIP Code/Codigo postal Relationship to Child/Relación al niño/a ([ ]) Work Phone/Número de trabajo

Medical Information/Información Medico

Physician’s Name/Nombre de Medico/a Insurance Company/Compañia de seguro médico

Phone Number/Número de teléfono Policy Number/Número de póliza

Allergies (including food and medicine)/Any Special Health Considerations/Any Medications Taken Regularly *Please note that CFY cannot administer any regularly-taken medications to your child. I authorize CFY to obtain immediate medical attention for my child in the case of an emergency, and I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. Parent’s/Guardian’s Signature/Firma de pariente o guardian Date/Fecha

I give permission for my child to take public transportation for CFY SST activities and attend CFY SST field trips around the New York City area. I release CFY and its officers, directors, employees, agents, successors and assigns from liability in case of accident, casualty and/or event which might occur during activities related to CFY and SST. I confirm that I have listed above all of my child’s allergies, special health considerations, medications, and medical issues/problems above, to the best of my knowledge. Parent’s/Guardian’s Signature/Firma de pariente o guardian Witness Signature/Firma de testigo Date/Fecha Date/Fecha