Online Emergency Contact Form

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

Home phone

Work phone

Cell phone

Parent home address (if different from child)
Street address

City

State

Zip code

Place of employment

Emergency contact name #1 (required)

Cell

Work

Emergency contact name #2 (required)

Cell

Work

Child's usual source of medical care

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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