Child's Name (required)
Home address (required)
Zip code (required)
Parent or guardian name (required)
Parent home address (if different from child)
Place of employment
Parent or guardian name
Emergency contact name #1 (required)
Emergency contact name #2 (required)
Special conditions, disabilities, allergies, or medical information for emergency situations:
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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