Teen Center Emergency Medical FormEmergency Medical Information, HIPAA Compliant – Teen CenterInvoice # (from Registration invoice or email)(Required)Student's First Name(Required)Student's Last Name(Required)Date of Birth(Required) Month Day YearAddress incl city, ST, zip code(Required)Home PhoneEmail(Required) Parent/Guardian #1 Name(Required)Cell/ Business Phone(Required)Parent/ Guardian # 2 nameCell/ Business PhoneIn 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)Consent(Required) I agree to emergency medical care In the event of an emergency and I cannot be reached, I give my permission for my son/daughter to be given immediate medical care at a hostpiatl or other medical/dental faciltyDoctor's NameDoctor' PhoneTO 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 NoMedication taken daily(Required)Other commentsDate of Last Physical(Required)Name of Parent/Guardian who will be signing for form submission(Required) First Last CommentsThis field is for validation purposes and should be left unchanged.
