Searcy Faith - Emergency Medical Information Form

Emergency Medical Information Form

First Name

Last Name

Birthdate

Father/Occupation

Mother/Occupation

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Emergency Contacts (other than parents) to contact in case of emergency.

Relation/Phone #

Does your child take any regular medications?

Yes/No

Is your child allergic to any medications? If Yes please list

Yes/No

Allergies:

Has your child ever had an operation? If Yes please list

Yes/No

Operation(s)

Does your child have, has, or ever had any of the following?

Does your child get nervous or upset easily?

Yes/No

May we give Aspirin, Tylenol, or Advil for pain and/or fever?

Yes/No

What is the date of your child's last physical exam?

Date Input

What is the date of your child's last Tetanus shot?

Date Input

Can your child swim?

Yes/No

What skill level are they in swimming?

Level

Is there any other information or medical conditions that might be useful for us to know?

Information/Medical Conditions