Swim for Fun

Aquatics Program

EMERGENCY CONTACT & MEDICAL FORM

           Student’s Name  ______________________     ________________________

      Last                                               First

Birthdate  ___________________  Age  ______  Sex  ______

Parent’s/Guardian’s Name  ____________    _____________   _____________

                                                Mother                    Father                    Last

Home Address  _______________________    _____________    __________     

                                                                                  City                            Zip

Other Address  _______________________    _____________    ___________

                                                                           City                       Zip

Phone        Home  ___________ Business  ___________ Other ____________

Email  Address:        _______________________________________________

Place of Employment     _____________________________    _____________

                                           Father                                                         Phone

                                           _____________________________    _____________

                                           Mother                                                          Phone

Name and phone number of a close relative or friend with whom we can leave a message:

               _________________________    ________________

                          Name                                                    Phone

Name of Family Doctor  ______________________________   ____________

                                                                                                               Phone

Does the student have any allergies?_____   If yes to what?  _______________________________________________________________

Does the student take any medications?  _____   If yes, what?  _______________________________________________________________

_______________________________________________________________

Does the student have any learning or physical disabilities? _______________________________________________________________

_______________________________________________________________

___________________________________       _____________________

            Parent’s Signature                                                     Date