Rec Emergency Card
This form is mandatory for all participants and must be filled out with updated information.
Do not forget to follow us on Facebook at HFCSD Recreation. The Facebook page provides real time updates and other useful info for all of our programs. See you soon!

Sign in to Google to save your progress. Learn more
Email *
Please select the following program you will be attending: *
Participants name: *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Parent/Guardian Name: *
Best number to reach parent/Guardian: *
Authorized Pick up and Emergency Contact Information: Contact #1: *
Emergency Contact #1 phone number: *
Contact #2 Name and phone number *
Family Physician: *
Physician's Phone Number: *
In the event of a medical emergency, I give permission for  __________________________________________to receive emergency medical transportation and treatment at the nearest medical facility. By adding your child's name below your are granted permission for the services above. *
  MEDICAL INSURANCE PROVIDER/COMPANY" *
INSURANCE I.D.# *
PARENT/GUARDIAN e-SIGNATURE *
Date *
MM
/
DD
/
YYYY
Does your child have any of the following medical diagnosis and if “yes” do they require any Medication? *
Required
If you answered answered yes to any of the conditions above please explain treatment and other helpful info. If there are any other special considerations that we should be aware of please state those below as well. Example: medicine names, other allergies etc... *
By electronically signing and dating below (Parent/Legal Guardian) you hereby give (child) permission to attend the Hudson Falls Central School District Recreation program. Furthermore, I understand the Hudson Falls Central School District Recreation Department may photograph or videotape the events or activity in which my child is participating.  I give permission for the Recreation Dept. to use photographs or videotape of me and my child for the purpose of promoting the Hudson Falls Central School District Recreation on Flyers and/or Website.  I give permission with the following understanding: No compensation of any kind will be paid to me (or my child) at this time or in the future for the use of my or my child’s likeness. By signing below, I hereby acknowledge and accept the above statements.                                                       *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Hudson Falls Central School District. Report Abuse
Google Forms