B8-MEDICAL AND EMERGENCY CONTACT INFORMATION

Select Youth Group Below
Minor Name Minor Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Date of Birth Date of Birth / MM / DD YYYY
Physician Name, Address, and Phone number

Below Please check any current health conditions that may require attention during the Program day.
	Yes	No
Anemia	AnemiaYes	AnemiaNo
Asthma Inhaler required?	Asthma Inhaler required?Yes	Asthma Inhaler required?No
Attention Deficit Hyperactivity	Attention Deficit HyperactivityYes	Attention Deficit HyperactivityNo
Disorder	DisorderYes	DisorderNo
Diabetes	DiabetesYes	DiabetesNo
EpiPen Injections required?	EpiPen Injections required?Yes	EpiPen Injections required?No
Food Allergies	Food AllergiesYes	Food AllergiesNo
Hearing Loss	Hearing LossYes	Hearing LossNo
ASL interpreter required?	ASL interpreter required?Yes	ASL interpreter required?No
Hearing Assistant required?	Hearing Assistant required?Yes	Hearing Assistant required?No
Headaches or Migraines	Headaches or MigrainesYes	Headaches or MigrainesNo
Heart Disease	Heart DiseaseYes	Heart DiseaseNo
Mobility Issues	Mobility IssuesYes	Mobility IssuesNo
Seizure Disorder (i.e., epilepsy)	Seizure Disorder (i.e., epilepsy)Yes	Seizure Disorder (i.e., epilepsy)No
Sensitivities (i.e., insect bites)	Sensitivities (i.e., insect bites)Yes	Sensitivities (i.e., insect bites)No
Vision Problems	Vision ProblemsYes	Vision ProblemsNo
Contact lenses required?	Contact lenses required?Yes	Contact lenses required?No
Eyeglasses required?	Eyeglasses required?Yes	Eyeglasses required?No

Specify Food Allergies:
Specify Mobility Issues:
Specify Sensitivities Issues:
Are any other conditions or restrictions required? Please specify.
The Parent/Guardian may stay or return to administer any required medications to a youth participant.

EMERGENCY CONTACT
Name of Parent/ Guardian #1 Name of Parent/ Guardian #1 First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Name of Parent/ Guardian #2 Name of Parent/ Guardian #2 First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/our child.
Name #1 Name #1 First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Name #2 Name #2 First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
If the Program is unable to reach any of the individuals named above promptly by phone, I/we authorize the Program to seek and secure any emergency medical or surgical care for my/our child. I/We will be responsible for all expenses incurred and authorize the medical facility at which treatment is rendered all necessary information to my/our insurance company.
Parent/ Guardian Signature #1: Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent/ Guardian Signature #2:Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

B8-MEDICAL AND EMERGENCY CONTACT INFORMATION

B8-MEDICAL AND EMERGENCY CONTACT INFORMATION

The Parent/Guardian may stay or return to administer any required medications to a youth participant. EMERGENCY CONTACT

If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/our child.

The Parent/Guardian may stay or return to administer any required medications to a youth participant.

EMERGENCY CONTACT