Swim for Fun

Aquatics Program

 

EMERGENCY CONTACT & MEDICAL FORM

 

†††††††††† Studentís Name______________________†††† ________________________

††††† Last†††††††††††††††††††††††††††††††††† ††††††††††† First

Birthdate___________________Age______Sex______

 

Parentís/Guardianís Name____________††† _____________†† _____________

††††††††††††††††††††††††††††††††††† ††††††††††† Mother††††††††††† ††††††† Father†††† †††††††††††††† Last

Home Address_______________________††† _____________††† __________†††††

†††† †††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††City†††††††††††††††††† †††††††† Zip

Other Address_______________________††† _____________††† ___________

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† City††††††††††††† †††††††† Zip

Phone††††††† Home___________ Business___________ Other ____________

 

EmailAddress:††††††† _______________________________________________

 

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? _______________________________________________________________

 

_______________________________________________________________

 

___________________________________†††††† _____________________

††††††††††† Parentís Signature††††††††††††††††††††††††††††††††††††††† †††††††††††† Date