EMERGENCY INFORMATION

Child's Name:__________________________________Birthday:_______________________

Home Address:_______________________________________________________________

Home Phone:____________________________________

Father's Name:___________________________________

Mother's Name:__________________________________

Contact Information:

Father: home:___________________________ mobile:____________________________

             work:___________________________e-mail:_____________________________

Mother: home:__________________________mobile:____________________________

             work:___________________________ e-mail:____________________________

Alternate Emergency Contact Person(s) :

Name: ______________________________________Phone:__________________

Name: ______________________________________Phone:__________________

Name: ______________________________________Phone:__________________

Medical Information (allergies to medication, food, other substances, etc.):
________________________________________________________________________
________________________________________________________________________
Hospital Prefernce:_________________________________________________________
Child's Doctor:____________________________Phone:___________________________
I agree that the operator may authorize the physician of his/her choice to provide emergency medical care in the event that neither I, my spouse, alternate contact(s), nor my child's doctor can be located immediately.

Parent's Signature:________________________________ Date:____________________

Operator's Signature:______________________________ Date:____________________