MEDICAL INFORMATION FOR PARTICIPATING CHILDREN AND YOUTH
 

Name of Child or Youth *
Name of Child or Youth
Home Address of the Child or Youth *
Home Address of the Child or Youth
Home Phone *
Home Phone
Name of Parent or Guardian *
Name of Parent or Guardian
Emergency/Cell Phone *
Emergency/Cell Phone
If you cannot reach me, the following individual may be contacted *
If you cannot reach me, the following individual may be contacted
Emergency contact phone number
Emergency contact phone number
Child's physician's name *
Child's physician's name
Child's physician's contact number *
Child's physician's contact number
Child's dentist's name
Child's dentist's name
Child's dentist contact number
Child's dentist contact number
Please check one of the two boxes below for instructions on administering medications
By typing my name I signify that all the information above is accurate and complete