Medical Form - FriendshipCT.com

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

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 Hour Minutes
Should be Empty:

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