360° Studio Emergency Form Address:​____​ ​Str

January 15, 2018 | Author: Anonymous | Category: N/A
Share Embed


Short Description

Download 360° Studio Emergency Form Address:​____​ ​Str...

Description

 

   

  

360° Studio Emergency Form    Learner Name:​ ___________________________________________  ​ Date of Birth:​ ___________________     Last                                                           First     ​

  Parent/Guardian​ :​ __________________________________ Ph:_____________________________________                                              Last                                         First                                      cell                                                                         work/home    Parent/Guardian:​ __________________________________ Ph:_____________________________________                                    ​   ​  Last                                                 First                            cell                                                                          work/home   

Main Email Address: ______________________________________________________________________________ 

  Address:​ ____​ ______________________________________________________________________ 

                   ​ Street                                                                        City                                                                 State                   Zip Code 

  Primary Emergency Contact Name:​ _______________________________________________________                                                                                              ​ Last                                                         First    Relationship:​  ​ _____________________________________________________________________________ 

 

Home Phone:​  _______________________ ​ Cell: _ ​_________________________ ​ Work:​  _​ _____________________ 

 

Secondary Emergency Contact Name:​ ______​ ________________________________________________                                                                                     ​ Last                                                      First    Relationship: ​ _____________________________________________________________________________________    Home Phone:​   ______________________ ​ Cell: ​ __________________________ ​ Work: ​ _________________________    Preferred Local Hospital: ​ ___________________________________________________________________________    Insurance Information:  Company:​  ______________________________________________ ​ Policy #:​  _________________________________    Sibling(s) in 360?  Y or  N      Name/grade(s):​ ___________________________________________________________    Allergies:   Y  or  N                                                Epi­pen dependant?  Y  or  N   List specific allergens​ :      Special physical/emotional health conditions?   Y  or  N      Comments on back​  ­ include any special medical or personal information you would want an  emergency care provider to know – or special contact information:    I authorize all medical and surgical treatment, x­rays, laboratory, anesthesia, and other medical/hospital  procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and  waive my right to informed consent of treatment. This waiver ​ only​  applies in the event that neither  parent/guardian can be reached by phone in the case of an emergency. 

 

Signature: ​ _____________________________________________________​  Date: ​ ____________________________ 

View more...

Comments

Copyright © 2017 HUGEPDF Inc.