Emergency Medical Form • Borough of Morris Plains, NJ

This form is HIPAA compliant through data encryption. After completing the form, you will receive onscreen notification of successful submission, but no email notification.

Emergency Medical Information (Minors Only)

Student's First Name(Required)

Student's Last Name(Required)

Date of Birth(Required)

Address incl city, ST, zip code(Required)

Home Phone

Email(Required)

Parent/Guardian #1 Name

Cell/ Business Phone

Parent/ Guardian # 2 name

Cell/ Business Phone

In case of illness, please list names and telephone numbers to be called in emergency if parent cannot be reached.

Name of Emergency Contact #1(Required)

Phone(Required)

Name of Emergency Contact #2(Required)

Phone(Required)

Doctor's Name

Doctor' Phone

TO BE COMPLETED BY PARENT (Please fill in these fields with any information that should be known by Recreation staff. SInce they are required fields, please write N/A or none if the question does not apply to your child).

Medical/Orthopedic/Emotional Conditions(Required)

Allergies(Required)

Does your child use an epi-pen(Required)

Yes

Medication taken daily(Required)

Other comments

Date of Last Physical(Required)

Name of Parent/Guardian who will be signing for form submission(Required)

First Last

Contact Us

Morris Plains Community Center, 51 Jim Fear Drive, Morris Plains, NJ 07950.

Hours of Operation: Monday through Thursday, 9:00 a.m. until 4:00 p.m.

Karleen Leahey, Recreation Director and Secretary to the Recreation Commission

Telephone: 973-538-3544

Email: kleahey@morrisplainsboro.org

This form is HIPAA compliant through data encryption. After completing the form, you will receive onscreen notification of successful submission, but no email notification.

Emergency Medical Information (Minors Only)

Contact Us

Recreation, Camp and Pool Alerts

Summer Recreation Programs – Details and Registration avail mid April

Easter Bunny Coming to Town April 1st

April 19th Book Club

Spring Tennis Registration