Child Emergency Contact Form

Child Emergency Contact Form
Child Information
Name
First NameLast Name
Birth Date
Ex. 14/04/2010
Blood Type
Ex. A+
Address
Street Address
Street Address Line 2
CityState
Zip CodeCountry
Parent/Guardian Information
(Will be contacted in an emergency situation)
Name
First NameLast Name
Phone Number (Cell)
Format: (000) 000-0000.
Phone Number (Work)
Format: (000) 000-0000.
Relationship Status
Other
Work Status
Employed
Emergency Contact Information
(If the parent/guardian is unavailable)
Name
First NameLast Name
Phone Number (Cell)
Format: (000) 000-0000.
Child Health Information
Special Conditions
Disabilities, chronic illnesses etc. (if any)
The child has Health Insurance:
Yes
Other Notes
Emergency Agreement
As the child's parent/guardian, by signing this field I agree to be responsible for all the charges which are excluded from health insurance in an emergency situation. If my child has no health insurance, I also agree to be responsible of all the charges about my child's health.
Clear
Should be Empty:

Child Information