Child Emergency Contact & Medical Information Form
Child Information
Child’s Full Name
Date of Birth
Age
Home Address
Parent/Guardian Information
Parent/Guardian 1 Name
Phone Number
Parent/Guardian 2 Name
Phone Number
Emergency Contacts (Other than Parents/Guardians)
Contact Name
Relationship
Phone Number
Contact Name
Relationship
Phone Number
Medical Information
Physician Name
Physician Phone
Insurance Provider
Policy #
Allergies
Medications
Medical Conditions/Special Instructions
Authorization
By signing below, I authorize emergency medical treatment for my child if necessary.
Parent/Guardian Signature
Date