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