Emergency Contact and Medical Information for a Child

M

F

Child’s Name

Date of Birth

Sex

Parent’s/Guardian’s Name

Parent’s/Guardian’s Name

(      )

(      )

(     )

(     )

Home Phone

Work Phone

Home Phone

Work Phone

Address

Address

City, ST  ZIP Code

City, ST  ZIP Code

Alternative Emergency Contacts

Primary Emergency Contact

Secondary Emergency Contact

(     )

(    )

(    )

(     )

Home Phone

Work Phone

Home Phone

Work Phone

Address

Address

City, ST  ZIP Code

City, ST  ZIP Code

Medical Information

Hospital/Clinic Preference

Physician’s Name

Phone Number

Insurance Company

Policy Number

Allergies/Special Health Considerations

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the even that neither parent/guardian can be reached in the case of an emergency.

Parent’s/Guardian’s Signature

Date