First Presbyterian Church, Endicott
Junior and Senior High Youth
Emergency Medical Information
September 1, 2009 - August 31, 2010
Name:______________________________________Birth Date:__________________________
Address:____________________________________________________________________
Parent/Guardian:_____________________Phone # (home)___________(work/cell)___________
Parent/Guardian:_____________________Phone # (home)___________(work/cell)___________
Emergency Contact if parents cannot be reached: _____________________Phone:___________
Family Doctor:_______________________________________________________________
Address & Phone Number:______________________________________________________
Dentist:_____________________________________________________________________
Address & Phone Number:_____________________________________________________
Insurance Co. and Name of Insured: ____________________ ___________________________
Policy Number & Group Number: ______________________ ___________________________Does your child have allergies, medical conditions, or physical impairments that we should be
aware of?
_____________________________________________________________________
_____________________________________________________________________________
Is your child on any type of medication at this time?____________________________________
_____________________________________________________________________________
Do we have permission to give your child the following medication if needed?
Is there anything else it would help us to know about your child so that we might provide a safe,
nurturing environment for him/her? ________________________________________________
____________________________________________________________________________