Child Emergency Contact and Consent Form
Child Information
Full Name
Date of Birth
Age
Address
Parent / Guardian Information
Full Name
Relationship
Phone Number
Email
Emergency Contacts
Contact Name
Relationship
Phone Number
Contact Name
Relationship
Phone Number
Medical Information
Physician Name
Physician Phone
Medical Conditions / Allergies
Current Medications
Health Insurance Information
Permissions and Consents
I authorize emergency medical treatment if necessary.
I give permission for my child to be transported for emergency medical care.
I consent do not consent to my child's photograph being used for program purposes.
Parent / Guardian Signature
Signature
Date