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Emergency Form PDF Print E-mail
Written by Jill Dempsey   
Saturday, 27 August 2011 01:03

Emergency Contact and Medical Information for a Child
 
 
 
 
 
 
Child’s Name   Child’s Last Name                        Grade
 
Date of Birth                                         Sex
 
 
 
«
Mother/Guardian’s First and Last Name
 
 
 
Father/Guardian’s First and Last Name
 
 
Home Phone                           Cell Phone
 
 
Home Phone                         Cell Phone
 
Work Phone
 
Work Phone
 
 
 
 
 
 
 
 
 
 
 
Address
 
Address
 
 
 
City, ST ZIP Code
 
 
City, ST ZIP Code
 
Email address
 
Email address
 
 
 
Alternative Emergency Contacts
 
 
 
 
Primary Emergency Contact
 
Secondary Emergency Contact
 
 
 
 
        
 
 
Home Phone
 
Work Phone
 
Home Phone
 
Work Phone
 
 
 
Address
 
Address
 
 
 
City, ST ZIP Code
 
City, ST  ZIP Code
 
 
 
Medical Information
 
 
Hospital/Clinic Preference
 
 
 
Physician’s Name
 
Phone Number
 
 
 
Insurance Company
 
Policy Number
 
Allergies/Special Health Considerations/Medications
 
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
 
Date
 
I give permission for my child to go on field trips. I release and individuals from liability in case off accident during activities related to St. Mary of Mt. Carmel School, as long as normal safety procedures have been taken.
 
 
 
Parent’s/Guardian’s Signature
 
Date