Morris Plains the Community of Caring
531 Speedwell Ave, Morris Plains, NJ 07950     973-538-2224

Teen Center Emergency Medical Form

Emergency Medical Information, HIPAA Compliant – Teen Center

Date of Birth(Required)
In case of illness, please list names and telephone numbers to be called in emergency if parent cannot be reached.
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).
Does your child use an epi-pen(Required)
Name of Parent/Guardian who will be signing for form submission(Required)
This field is for validation purposes and should be left unchanged.