Download and use this form for Maintaining a Child Emergency Contact and Medical Information records with schools, playhouse or other institutions where your child spends most of his time.
Child emergency contact and medical information form
Text Version of this Form
Emergency Contact and Medical Information for a Child
M F
Child’s Name Date of Birth Sex
Parent’s/Guardian’s Name Parent’s/Guardian’s Name
Home Phone Work Phone Home Phone Work Phone
Address Address
City, ST ZIP Code City, ST ZIP Code
Alternative Emergency Contacts
Primary Emergency Contact Secondary Emergency Contact
Home Phone Work Phone Home Phone Work Phone
Address Address
City, ST ZIP Code City, ST ZIP Code
Medical Information
Hospital/Clinic Preference
Physician’s Name Phone Number
Insurance Company Policy Number
Allergies/Special Health Considerations
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or 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 applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Parent’s/Guardian’s Signature Date
I give permission for my child to go on field trips. I release [Organization] and individuals from liability in case of accident during activities
related to [Organization], as long as normal safety procedures have been taken.
Parent’s/Guardian’s Signature Date
Witness Signature Date