Child's Name: Event: Event Date: Address: City/Town: State: Zip Code: Mother's Name: Mother's Cell Phone Mother's Email:
Father's Name: Father's Cell Phone: Father Email:
Emergency Contact information: Emergency Contact #1 Name: Emergency Contact #1 Cell Phone Number: Emergency Contact #1 Home Phone Number: Emergency Contact #1 Work Phone Number:
Emergency Contact #2 Name: Emergency Contact #2 Cell Phone Number: Emergency Contact #2 Home Phone Number: Emergency Contact #2 Work Phone Number:
Allergies or Special Concerns: Dare of Last Tetanus:
Insurance Company Name: Insurance Company Address: Insurance Policy Number:
Family Physician: Physician's Address: Physician's Phone number: Present Illnesses: Present Medications:
Policy Holder: State: State: Home Phone: Work Phone: Zip Code:
In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation in the above event, every reasonable effort will be made to contact the persons listed on this form. If unsuccessful in contacting the persons listed, consent/permission is given for treatment by competent medical personnel. Further, and unless specified otherwise, consent/permission is hereby given to all accompanying adult volunteer leaders at this event to hospitalize, secure proper treatment for, and/or injection, anesthesia or surgery (under recommendation of qualified medical personnel).
I agree that my insurance company will be used for such medical care and expenses and I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payments of medical bills.
Sign: (Type Name): Date:
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