Emergency Contact Form
PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.
Camp Enrolled
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Middletown Teen Theater
Middletown Children's Theater
MCT: Tiny Tots
Choose One
Camper Name
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First Name
Last Name
Birthdate
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Month
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Day
Year
Date Picker Icon
Mother's Name
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First Name
Last Name
Daytime Phone:
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Area Code
Phone Number
Father's Name
First Name
Last Name
Daytime Phone:
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Area Code
Phone Number
Guardian's Name
First Name
Last Name
Email
*
Confirmation Email
PLEASE double check for accuracy
Back
Next
MEDICAL INFORMATION
Please double check for accuracy.
Physician:
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Physician's Phone:
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Area Code
Phone Number
Dentist:
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Dentist's Phone
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Area Code
Phone Number
Name of Insured
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First Name
Last Name
Insurance Company
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Insurance Phone Number
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Area Code
Phone Number
Employer Group Name
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Group Number
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ID #
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Current Medications
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If none, please type N/A
Allergies
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If none, please type N/A
Pertinent Medical History
*
If none, please type N/A
Please click to accept:
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I, as the parent or legal guardian of the minor child, hereby acknowledge that the forenamed minor is covered by medical and prescription drug insurance.
Submit Form
Should be Empty: