ID & Emergency Info
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ID & Emergency Info |
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Camp Rescue Rangers |
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  Rescue Rangers Camp IDENTIFICATION AND EMERGENCY INFORMATION CHILD’S NAME
LAST MIDDLE
FIRST SEX Telephone ( ) ADDRESS
NUMBER
STREET CITY
STATE ZIP Birthday FATHER’S
NAME LAST
MIDDLE
FIRST Business Telephone ( ) HOME ADDRESS
NUMBER
STREET
CITY STATE
ZIP Home Telephone ( ) MOTHER’S NAME LAST
MIDDLE
FIRST Business Telephone ( ) HOME ADDRESS
NUMBER
STREET
CITY STATE ZIP Home Telephone ( ) PERSON RESPONSIBLE FOR CHILD LAST NAME
MIDDLE FIRST HOME TELEPHONE (
) Business Telephone ( ) ADDITIONAL PERSONS WHO MAY BE CALLED IN
AN EMERGENCY NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN AN
EMERGENCY PHYSICIAN
ADDRESS
MEDICAL PLAN AND NUMBER Telephone (
) DENTIST
ADDRESS
MEDICAL PLAN AND NUMBER Telephone (
) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL / OTHER
EXPLAIN: CAN CAMP STAFF
ADMINISTER ANY OF THE FOLLOWING: Tylenol
Advil
Benadryl
Tums
Other NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL
NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) NAME RELATIONSHIP TIME CHILD WILL BE CALLED FOR SIGNATURE OF PARENT OR AUTHORIZED REPRESENTATIVE DATE |
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