Emergency Contact/Parental Consent Form

Grand View Health > Grand View Health Children’s Center > Summer Camp > Emergency Contact/Parental Consent Form

Child's Information
Name * Required
First Last
Date of Birth
MM slash DD slash YYYY
Address * Required
Street Address Address Line 2 City State ZIP Code
Mother's / Legal Guardian's Information
Name
First Last
Home Telephone Number
Home Address
Street Address Address Line 2 City State ZIP Code
Business Name
Business Telephone Number
Business Address
Street Address Address Line 2 City State ZIP Code
Father's / Legal Guardian's Information
Name
First Last
Home Telephone Number
Home Address
Street Address Address Line 2 City State ZIP Code
Business Name
Business Telephone Number
Business Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact Person(s)
#1 Name
First Last
#1 Telephone Number When Child is in Care
#2 Name
First Last
#2 Telephone Number When Child is in Care
#3 Name
First Last
#3 Telephone Number When Child is in Care
Person(s) to Whom Child May be Released
#1 Name
First Last
#1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
#1 Telephone Number When Child is in Care
#2 Name
First Last
#2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
#2 Telephone Number When Child is in Care
#3 Name
First Last
#3 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
#3 Telephone Number When Child is in Care
Child's Physician / Medical Care Provider
Name
Telephone Number
Address
Street Address Address Line 2 City State ZIP Code
Special Disabilities (if any)
Allergies (including medication reaction)
Medical or Dietary Information Necessary in an Emergency Situation
Medication, Special Conditions
Additional Information or Special Needs of Child
Health Insurance Coverage for Child or Medical Assistance Benefits
Policy Number * Required
Parent's Signature is Required for Each Item Below to Indicate Parental Consent
Obtaining Emergency Medical Care * Required
Admin. of Minor First-Aid Procedures * Required
Transportation by the Facility * Required
Walks and Trips * Required
Swimming * Required
Wading * Required
Signature of Parent or Guardian * Required
Signature of Parent or Guardian
Email
This field is for validation purposes and should be left unchanged.

Child's Information

Mother's / Legal Guardian's Information

Father's / Legal Guardian's Information

Emergency Contact Person(s)

Person(s) to Whom Child May be Released

Child's Physician / Medical Care Provider

Parent's Signature is Required for Each Item Below to Indicate Parental Consent