Child's Name* MEDICAL EMERGENCIES A. In case of emergency, when neither parent can be reached, please provide names of two people who will take responsibility for your child: Person #1 Full Name:* First Name Last Name Phone Number* Area Code Phone Number Relationship to child* Person #2 Full Name:* First Name Last Name Phone Number* Area Code Phone Number Relationship to Child* B. If parents cannot be reached, and emergency medical attention is needed, permission is given to the Friendship Circle staff to call my child's doctor. Doctor Name* Dr's Name Practice Phone Number* Area Code Phone Number Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Doctor's Hospital Affiliation C. In case of medical emergency requiring immediate care, I authorize the paramedics to take my child to the nearest hospital, if necessary. Health Insurance Name and Policy Number: D. Allergies & Medications Allergic reactions to medications: Medication child is taking on regular basis: Food Allergies: Any special Medical Circumstances: E. I authorize the Friendship Circle to administer prescription or patent medicine to my child as specified in written instructions. Parent Signature:* First Name Last Name Date:* Month Day Year at 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM Submit Should be Empty: This page uses TLS encryption to keep your data secure.