Dad's / Primary Guardian's Information
Mom's / Secondary Guardian's Information
Complete the next 7 lines only where different from Dad's / Primary Guardian's information
Emergency Contact - Someone other than listed above
Doctor Contact Information
Note: Serving children 4 years of age thru children starting 5th grade in fall of 2013. Pre-K children, must have turned 4 years of age in 2012 in order to participate.
Information about Child #1
Information about Child #2
Information about Child #3
Information about Child #4
Please arrive at 8:45 on Saturday morning so that you can validate the above information and sign the medical emergency care authorization.