1. No category

Emergency Contact, Medical Information/Release
Emergency Contact and Medical Information for a Child
Child’s Name
Date of Birth
Parent’s/Guardian’s Name
Parent’s/Guardian’s Name
Home Phone
Work Phone
Sex (M/F)
Home Phone
Address
Address
City, ST ZIP Code
City, ST ZIP Code
Work Phone
Alternative Emergency Contacts
Primary Emergency Contact & Relationship
Home/Cell Phone
Secondary Emergency Contact & Relationship
Work Phone
Home/Cell Phone
Address
Address
City, ST ZIP Code
City, ST ZIP Code
Work Phone
Medical Information
Hospital/Clinic Preference
Physician’s Name
Phone Number
Insurance Company
Policy Number
Allergies/Special Health Considerations (Please be sure to note any food or health allergies)
Medications (prescribed or over the counter)
Provider Certification
I attest that the information above is accurate and has not been falsified or altered in any manner. Should it be found that information was
reported erroneously, I understand that my child will be removed promptly from the College Reach-Out Program until further notice.
Parent’s/Guardian’s Name
Parent’s/Guardian’s Signature
Date