RLCA Emergency Contact and Parental Consent Form - Resurrected Community Development Corp

RLCA Emergency Contact/Parental Consent Form

55 PA CODE CHAPTERS 3270.12 (a) (b), 3270. 181 & 182: 3280. 124 (a) (b), 3280. 181 & 182: 3290. 124 (a) (b), 3290. 181 & 182

Child's Name

First Last

Birthdate

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother's Name/Legal Guardian

First Last

Home Telephone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Name

Business Telephone Number

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father's Name/Legal Guardian

First Last

Home Telephone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Name

Business Telephone Number

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Person(s)

Name

Telephone Number (When in care)

Person(s) Whom Child May Be Released

Name

Address

Telephone Number (When in care)

Name of Child's Physician/Medical Care Provider

Physician/Medical Care Provider's Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Special Disability (if any)

Allergies (including medication reaction)

Medical or Dietary information necessary in an emergency situation

If none, please write N/A

Medication and/or Special Conditions

Additional information on special needs of child

Health insurance coverage for child, or medical assistance benefits

Policy Number(Required)

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