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Child Information
First Name
Last Name
Middle Initial
Preferred Name
Age
Birth Date
/
/
School
Year
Parent(s) / Guardian(s) Information
First Name
Last Name
Middle Initial
Relationship to Child
Father
Mother
Legal Guardian
Other
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
This is the Child's primary residence
Parent(s) / Guardian(s) Information
First Name
Last Name
Middle Initial
Relationship to Child
Father
Mother
Legal Guardian
Other
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
This is the Child's primary residence
Medical Information
Medical Insurance Company
Policy #
Physicians Name
Phone #
Medical Conditions
Please List any medical conditions that your child has that we should be aware of. Please include Allergies, Medical Allergies, Food Allergies, and any special dietary needs.
Medications
My child takes the following medications:
Prescription Name
Reason for use
Frequency of use
Prescription Name
Reason for use
Frequency of use
Prescription Name
Reason for use
Frequency of use
Emergency Contact Information
In case of emergency please call
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Please list any other information of importance
