Please be advised that all information on this form will be kept confidential. Answer all the questions, sign, and return with your application.
Name: Date of Birth:
Street Address: City:
State: Zip:
Phone Number: Email:
Is your child allergic to ANY foods or medicine?:
Is your child allergic to BEE STINGS? :
Does your child take any medication?: (If yes, please provide details)
Any physical activity he/she cannot participate in? :
Any other important health related information? :
Persons AUTHORIZED to pick up my child
1.
2.
3.
Name & Phone # of Doctor:
In case of emergency, we can be reached at the following phone numbers:
1: 2: 3:
If I CANNOT be reached, call
Or call
Parents or Guardian Authorization: In case of emergency, if family physician CANNOT be reached, I hereby authorize my child to be treated by “CERTIFIED EMERGENCY PERSONNEL” (i.e. EMT, first responder, ER Physician) YesNo
Parent Signature: Date: