Last name ___________________

 

Emergency Information Form

 

Required information:  PLEASE PRINT

 

Participantís Name ________________________________Birthdate__________

Address___________________________________________________________

Phone (day) _______________________ (evening)________________________

Parent or Guardian____________________ Phone (day)____________________

 

Health Insurance Carrier _________________________Policy Number ________

Health Insurance Telephone Number ___________________________________

Address __________________________________________________________

 

If Parent/Guardian cannot be reached in the case of an emergency, notify:

Nearest relative __________________________Relationship _______________

Address __________________________________________________________

Phone ____________________________________________________________

Friend or Neighbor ___________________________

Address___________________________________________________________

Phone __________________________________

 

Family Physician/Pediatrician _______________________ Phone _______________

Address _________________________________________________________

Date of last tetanus shot ___________________________

 

Any special medical problems or allergies  ____________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

 

Signature of Parent or Legal Guardian __________________________________

 

 

 

Note:  We are required by the Maryland State Department of Health and Mental Hygiene to have on file either a copy of your childís immunization record or documentation of your childís enrollment in a Maryland School.  We will accept a copy of your childís most recent report card from a Maryland school or a note on school letterhead confirming that he or she is a student.  Please attach.