Child's Name (required)
Birthdate (required)
Email (required)
Home address (required)
City (required)
State (required)
Zip code (required)
Parent or guardian name (required)
Home phone
Work phone
Cell phone
Parent home address (if different from child) Street address
City
State
Zip code
Place of employment
Parent or guardian name
Emergency contact name #1 (required)
Cell
Work
Emergency contact name #2 (required)
Doctor's name
Doctor's phone
Dentist's name
Dentist's phone
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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