Emergency and Identification Form
Child's Date of Birth
Parent/Guardian 1 Name
Parent/Guardian 2 Name
Address (if different)
Preferred contact in case of emergency. Name, phone, email
Additional persons who may be called in case of emergency. Name, phone, relationship.
Physician or Dentist to be called in case of emergency. Name
Medical Plan Information
If physician cannot be reached please
Call Emergency Hospital
if Other, please explain
Medical history, allergies, or injuries that may affect child's participation in program
Should be Empty:
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