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Minor Emergency Contact and Medical Information
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* Indicates required question
Email
*
Your email
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Sex
*
Female
Male
Prefer not to say
Other:
Child's Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian's Name
*
Your answer
Parent/Guardian's Phone Number
*
Your answer
Parent/Guardian's Email
Your answer
Parent/Guardian's Address
*
Your answer
Parent/Guardian's Name
Your answer
Parent/Guardian's Phone Number
Your answer
Parent/Guardian's Email
Your answer
Parent/Guardian's Address
Your answer
Alternative Primary Emergency Contact Name
*
Your answer
Alternative Primary Emergency Contact Phone Number
*
Your answer
Alternative Secondary Emergency Contact Name
Your answer
Alternative Secondary Emergency Contact Phone Number
Your answer
Child's Physician Name
*
Your answer
Physician's Phone Number
*
Your answer
Child's Dentist Name
*
Your answer
Dentist's Phone Number
*
Your answer
Preferred Hospital
*
Your answer
Health Insurance Company
*
Your answer
Policy Number
*
Your answer
Primary Policy Holder Name
*
Your answer
Child's Allergies (state none if your child does not have any allergies)
*
Your answer
Child's Medical Conditions/Special Health Considerations (state none if your child does not have any medical conditions)
*
Your answer
Child's Medications (state none if not currently taking any medications)
*
Your answer
Parent/Guardian Signature (by signing you are giving consent for necessary treatment to your child when all reasonable attempts have failed to reach you)
*
Your answer
Date
*
MM
/
DD
/
YYYY
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