RCCC Health/Medical Form/Emergency Permission to Treat

RCCC Health/Medical Form/Emergency Permission to Treat
Name of Singer

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian

First NameLast Name
Additional Parent/Guardian

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Doctor
Doctor Phone #
Date of Last Tetanus Shot

MonthDayYear
Name of Insurance Company
Group and Policy #
Current Health Problems/situations, prescription medication information
My child may be given acetaminophen or cough medication.

YesNo
Permission to Swim with adult supervision.

YesNo
Permission to ice skate with adult supervision.

YesNo
Electronically sign this form by entering your full name here.
Should be Empty: