Medical Information / Emergency Contact

Full Name     _______________________________    Gender  O Male    OFemale

Date of Birth  ______________________________

Full Address  _______________________________


Email            ________________________________

Parents’ Name (juniors) _______________________________________

Home phone _______________________ Cell phone________________________

Emergency Contact _______________________ Phone______________________

Health Insurance    ________________________ Policy No.____________________

Doctor and phone no.  _________________________________________________

Dental Insurance    ________________________ Policy No.____________________

Dentist and phone no.  _________________________________________________

Indicate medical condition, allergies, special needs including medication:________ ___________________________________________________________________

Parents’ permission for staff to give pain killers (acetaminophen or ibuprofen)      O yes  O no

In case of medical emergency, every effort will be made to contact the persons listed above before contacting the doctor.  Please sign below to authorize us to seek emergency care if deemed necessary.  This form will be given to emergency personnel.

Signature (parent/guardian if minor) _________________________  Date___________