PCS Fall Emergency Card 2021-22

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Please complete this form accurately and notify us of any updates. This form is needed in case of an emergency during after school or summer camp

Email *

Child's Full Name *

Family Physician *

Family Physician Address *

Family Physician Phone number *

Hospital preferred in case of emergency

Health Insurance *

Policy Number *

Person to be called in case of and accident or illness other than parents: (parents are called first for all emergencies) List: Name, Address, Phone number, Relationship

Is your child allergic to bee stings or other insect bites? *

Yes

If yes what treatment is necessary?

Medication

Hospitalization

Not Applicable

Clear selection

Name of medication(s) (Please send all labeled medication to the staff)

Is your child allergic to any drug(s)? *

Yes

If yes name of medication(s)

Any special health problems that the staff should know about?

Should a medical emergency occur, we will make every effort to contact you about treatment for your son/daughter. In the event you cannot be reached, we ask that you give us permission to provide emergency medical treatment and follow-up care by a licensed physician.In the event I cannot be reached by telephone, I grant permission to the 21st CCLC and its personnel to provide emergency treatment for my son/daughter. I agree that I will not hold the 21st CCLC personnel liable for any acts/omission relating to the emergency medical treatment provided to my son/daughter. Write your (parent or guardian's) name and the date to sign. *

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