Emergency Contact and Medical Information for a Child
M	F
Child’s Name	Date of Birth	Sex
Parent’s/Guardian’s Name	Parent’s/Guardian’s Name
Home Phone	Work Phone	Home Phone	Work Phone
Address	Address
City, ST ZIP Code	City, ST ZIP Code
Alternative Emergency Contacts
Primary Emergency Contact	Secondary Emergency Contact
Home Phone	Work Phone	Home Phone	Work Phone
Address	Address
City, ST ZIP Code	City, ST ZIP Code
Medical Information
Hospital/Clinic Preference
Physician’s Name	Phone Number
Insurance Company	Policy Number
Allergies/Special Health Considerations
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or 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.
Parent’s/Guardian’s Signature	Date
I give permission for my child to go on field trips. I release and individuals from liability in case of accident during activities related to , as long as normal safety procedures have been taken.
Parent’s/Guardian’s Signature	Date
Witness Signature	Date