Sts. John and Paul Religious Education Program
280
Weaver Street
Larchmont, NY 10538
FAMILY EMERGENCY FORM
2008 / 2009
LAST NAME of Child/Children: ___________________________________________
Address: ______________________________________________________________
First Name Age First
Name Age
__________________ _____ ___________________ _____
__________________ _____ ___________________ _____
MOTHER’S First and Last
Name: _________________________________________
Home Phone: _____________________Cell/Beeper: ________________________
Mother’s Business Phone:
_________________________________
Home Phone: _____________________Cell/Beeper: ________________________
Father’s Business Phone:
_________________________________
In case of emergency and
parent is not available, contact one of two:
1.
_____________________________________________________________________
Name Relationship to Family Phone
2.
_____________________________________________________________________
Name Relationship to Family Phone
Child’s Physician: _______________________________________________________
Name Phone
Child’s Dentist: _______________________________________________________
Name Phone
Please sign the following after reading:
In case of accident or illness, I
request that the representative of the parish catechetical program contact
me. If I am unable to be reached, I
hereby authorize this representative to call the physician indicated and to
follow the physician’s
I
agree to assume the financial responsibility for any diagnosis, treatment
and/or medication deemed necessary.
To
the best of my knowledge all information given is accurate and complete. I hereby consent to, and authorize the
necessary procedures that have been stated above.
__________________________________________ __________________
Signature
of parent or guardian Date
Please complete the following information in full:
HOSPITAL where student
should be taken if parent or physician is unavailable:
________________________________________________________________________
MEDICAL INSURANCE CO.:_____________________________________________
ID NUMBER:____________________GROUP NUMBER: _____________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Any allergies or other
medical conditions, please explain below.
(Information about non-emergency special needs or
learning issues should be
included on the registration form.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________________________________________________________________________________