Test3 Emergency Contact / Parental Consent If you are human, leave this field blank. Child Child's Name * Birthday * Home Address * Parent / Guardian 1 Parent / Guardian's Name * Home Address if different from above Work Name and Address Phone * Phone (Secondary) Email * Parent / Guardian 2 Parent / Guardian's Name Home Address if different from above Work Name and Address Phone if different from above Phone (Secondary) Email Emergency Contact Persons WILL BE CONTACTED IF PARENTS CANNOT BE REACHED. IT IS REQUIRED TO LIST THREE Name * Phone * Name * Phone * Name * Phone * Release PERSON(S) TO WHOM CHILD MAY BE RELEASED- PICK UP REGULARLY Name Phone Address Name Phone Address Name Phone Address Medical Physician / Health Care Provider Name * Phone * Address Health Insurance Coverage for Child or Medical Assistance Benefits * Policy Number * Special Disabilities (if any) Allergies (including Medication Reaction) Medical or Dietary Info Necessary in an Emergency Situation Medication / Special Conditions Additional Information on Special Needs of Child Commitment Signature of Parent/guardian * Draw It Type It Clear Submit Share Share on Twitter Share on Facebook SHARE ON PINTEREST Share on Google+