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) - Recreation

Do not use this form for Teen Center. There is a different form for Teen Center.

Invoice # (from Registration invoice or email)(Required)

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 or Teen Center 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) - Recreation

Contact Us

Recreation, Camp and Pool Alerts

January Book Club

Pickleball at the Community Center Sept 12- Apr 30

Summer Camp Registration

Community Park Pool Registration Open