Volunteer Emergency Contact Information
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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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