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Emergency Contact and Medical Information for a Child
 
 
 
 
M F
Child’s Name Date of Birth Sex
 
 
 
Parent’s/Guardian’s NameParent’s/Guardian’s Name
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Home PhoneWork PhoneHome PhoneWork Phone
 
AddressAddress
 
City, ST ZIP Code City, ST ZIP Code
 
Alternative Emergency Contacts
 
 
 
 
Primary EmergencyContactSecondary Emergency Contact
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Home PhoneWork PhoneHome PhoneWork Phone
 
 
 
AddressAddress
 
 
 
City, ST ZIP Code City, ST ZIP Code
 
Medical Information
 
 
Hospital/Clinic Preference
 
 
 
Physician’s NamePhone Number
 
 
 
Insurance CompanyPolicy 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 Sweet Home Swim Club and individuals from liability in case of accident during activities
related to Sweet Home Swim Club, as long as normal safety procedures have been taken.
 
 
 
Parent’s/Guardian’s Signature Date