Emergency Contact Information Form

Copyright 2010 Well Trained Mind

Child’s Name :

Parent’s/Guardian’s Name :

Home Phone :

Work Phone :

Address :

City :

State :

ZIP Codes :

Emergency Contact and Medical Information for a Child

Date of Birth :

Parent’s/Guardian’s Name :

Home Phone :

Work Phone :

Address :

City :

State :

ZIP Codes :

Sex :

Primary Emergency Contact :

Home Phone :

Work Phone :

Address :

City :

State :

ZIP Codes :

Alternative Emergency Contacts

Secondary Emergency Contact :

Home Phone :

Work Phone :

Address :

City :

State :

ZIP Codes :

Hospital/Clinic Preference :

Physician’s Name :

Phone Number :

Insurance Company :

Policy Number :

Allergies/Special Health Considerations :

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 event that neither parent/guardian can be reached in the case of an emergency.

Medical Information

[Organization], as long as normal safety procedures have been taken.

MaleFemale

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or

I give permission for my child to go on field trips. I release [Organization] and individuals from liability in case of accident during activities related to

Witness Name: