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Volunteer Emergency Contact Template


Volunteer emergency contact information to use for contacting key individuals.



Volunteer Emergency Contact Information Form



Volunteer Emergency Contact Information


Child's Name:

________________________________

DOB: ____/____/______

Street: _________________________

City: __________ State: ___ Zip: ____

Phone Number:

________________________________

Father:

________________________________

Phone Number:

______________________________

Cell Phone:

______________________________

Address: _________________________

City: __________ State: ___ Zip: ____

Place of Employment:

________________________________

Work Phone Number:

________________________________


Mother:

________________________________

Cell Phone Number:

________________________________

Phone Number:

________________________________

Street: _________________________

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:

________________________

Cell Phone:

______________________________

Address: _________________________

City: __________ State: ___ Zip: ____

Name: _________________________

Phone Number:

________________________

Cell Phone:

______________________________

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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