Teen Center Emergency Medical Form

Emergency Medical Information, HIPAA Compliant – Teen Center

Company

This field is for validation purposes and should be left unchanged.

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)

Primary Phone

Email(Required)

Parent/Guardian #1 Name(Required)

Cell/ Primary Phone(Required)

Parent/ Guardian # 2 name

Cell/ Primary 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/Behavioral 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

Teen Center Emergency Medical Form

Emergency Medical Information, HIPAA Compliant – Teen Center

Contact Us