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Volunteer Emergency Contact Information Form


Volunteer Emergency Contact Template

Volunteer emergency contact information to use for contacting key individuals.




Volunteer Emergency Contact Information


Child’s Name: _________________________________________ DOB: ____/____/______

Address: ______________________________________________________________________

City: _____________________________________ State: _____________ Zip: ______________


Father: ______________________________________________________________________

Phone Number: ________________________ Cell Phone: ______________________________

Address: ______________________________________________________________________

City: _____________________________________ State: _____________ Zip: ______________

Place of Employment: __________________________________________________________

Work Phone Number: __________________________________________________________


Mother: _____________________________________________________________________

Phone Number: ________________________ Cell Phone: ______________________________

Address: ______________________________________________________________________

City: _____________________________________ State: _____________ Zip: ______________

Place of Employment: __________________________________________________________

Work Phone Number: __________________________________________________________


Has your child ever been stung by a bee, wasp, etc.? _____________ More than once? _______

What was their reaction? _________________________________________________________

Have there been any recent operations, physical handicaps, allergies, or any other conditions that the coordinators should be aware of?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Two additional local individuals to notify in case we are unable to reach either parent.

Name: ________________________________________________________________________

Phone Number: ________________________________________________________________

Address: ______________________________________________________________________

City: _____________________________________ State: _____________ Zip: ______________

Name: ________________________________________________________________________

Phone Number: ________________________________________________________________

Address: ______________________________________________________________________

City: _____________________________________ State: _____________ Zip: ______________


Dentist: _____________________________________________________________________

Phone Number: ________________________________________________________________

Address: ______________________________________________________________________

City: _____________________________________ State: _____________ Zip: ______________


Doctor: ______________________________________________________________________

Phone Number: ________________________________________________________________

Address: ______________________________________________________________________

City: _____________________________________ State: _____________ Zip: ______________

Current Medication: _____________________________________________________________

Preferred Hospital: ______________________________________________________________

In case of emergency and treatment being necessary, I hereby grant the program officials to use their own judgment when sending the volunteer to the hospital or the doctor before necessarily contacting either parent or alternate.



________________________________
Parent or Guardian Signature





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