Emergency Information & Consent

Child’s Name: ________________________________________

Age: __________ M ____ F ____ Phone: ______________

Address: ____________________________________________

Any known allergies? (Y) (N) Please List: ________________________

_____________________________________________________________

_____________________________________________________________

Any other medical conditions we should know about? _____________

_____________________________________________________

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Mother: __________________ Father: ___________________

Work: ____________________ Work: ____________________

Cell/Pager: ________________ Cell/Pager: ________________

Emergency Contact: ___________________ Relation: _________

Phone: ___________________ Cell/Pager: ________________

Physician’s Name: ______________________________________

Address: ______________________________________________

Work Phone: ______________ Cell/Pager: _________________

Dentist’s Name: ______________________________________

Address: ______________________________________________

Work Phone: ______________ Cell/Pager: _________________

I hereby give my consent for PRUMC and its representatives to arrange for medical treatment for my child(ren) in the event that I cannot be reached in an emergency situation.

Parent/Legal Guardian: _______________________ Date: __________