Online Emergency Contact Form

    Home phone

    Work phone

    Cell phone

    Parent home address (if different from child)

    Home phone

    Work phone

    Cell phone

    Parent home address (if different from child)

    Cell

    Work

    Cell

    Work

    Child's usual source of medical care

    Doctor's phone

    Dentist's phone

    Parent/Legal Guardian Consent and Agreement for Emergencies

    As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.

    Signature required (use mouse or finger to sign)
    Parent or guardian #1

    Parent or guardian #2 (if applicable)

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