Medical and Emergency Contact Information

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Family Name *

Children's names and medical notes *

Please list each students name and write any medical notes behind each name such as asthma, allergies, etc.

Family Notes

List anything you think we might need to know about your family or its medical history to aid your child(ren) in the case of an emergency.

Primary Emergency Contact Name *

The person we call FIRST for any emergencies regarding the student(s). This usually is a Parent/Guardian.

Primary Emergency Contact Phone *

Emergency Relation *

Secondary Emergency Contact Name *

First and Last name of whom we call for urgent notifications when the PARENT/GUARDIAN(S) ARE UNREACHABLE.

Secondary Emergency Contact Phone *

Relationship

3rd Emergency Contact Name

First and Last name of whom we call for urgent notifications when the THE PRIMARY AND SECONDARY EMRGENCY CONTACTS ARE UNREACHABLE.

3rd Emergency Contact Phone

Relationship

Doctor Name *

Doctor Phone *

Hospital Preference

Insurance Provider

Insurance ID Number

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