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Camp/Lesson Form Required

 

 

EMERGENCY CONTACT / PARENTAL CONSENT FORM

CHILD'S NAME

BIRTH DATE

ADDRESS

MOTHER'S NAME/LEGAL GUARDIAN

HOME TELEPHONE NUMBER

ADDRESS

CELL NUMBER

BUSINESS NAME

BUSINESS TELEPHONE NUMBER

BUSINESS ADDRESS

FATHER'S NAME/LEGAL GUARDIAN

HOME TELEPHONE NUMBER

ADDRESS

CELL NUMBER

BUSINESS NAME

BUSINESS TELEPHONE NUMBER

BUSINESS ADDRESS

EMERGENCY CONTACT PERSON - NAME (1)

DAYTIME PHONE NUMBER

EMERGENCY CONTACT PERSON - NAME (2)

DAYTIME PHONE NUMBER

EMERGENCY CONTACT PERSON - NAME (3)

DAYTIME PHONE NUMBER

PERSON TO WHOM CHILD MAY BE RELEASED - NAME and ADDRESS (1)

DAYTIME PHONE NUMBER

PERSON TO WHOM CHILD MAY BE RELEASED - NAME and ADDRESS (2)

DAYTIME PHONE NUMBER

PERSON TO WHOM CHILD MAY BE RELEASED - NAME and ADDRESS (3)

DAYTIME PHONE NUMBER

NAME OF CHILD'S PHYSICIAN / MEDICAL CARE PROVIDER

TELEPHONE NUMBER

ADDRESS

SPECIAL DISABILITIES (IF ANY)

ALLERGIES INCLUDING MEDICATION REACTION

MEDICAL OR DIETARY INFORMATION NEEDED IN AN EMERGENCY

MEDICATION, SPECIAL CONDITIONS

ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD

HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS

POLICY NUMBER (REQUIRED)

PARENTS SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE

ADMINISTRATION OF MINOR FIRST - AID PROCEDURES

WALKS AND TRIPS

SWIMMING

TRANSPORTATION BY THE FACILITY

WADING

 

SIGNATURE OF PARENT OR GUARDIAN                                                                        DATE

SIGNATURE OF PARENT OR GUARDIAN                                                                        DATE

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