UNITY IS OUR GREATEST STRENGTH
In case of an emergency, the Jetz All –Star staff will contact 911. Every attempt will be made to contact a parent, a guardian, or a designated emergency contact. Child’s Name: Date of Birth: Parent / Guardian Contact Information: Name: Telephone: Address: Work Phone: City: State: Zip Code: Relation: Language: Email: Parent / Guardian Contact Information: Name: Telephone: Address: Work Phone: City: State: Zip Code: Relation: Language: Email: Other Contact Information Please list three people we may call if the parent(s) or guardian(s) cannot be reached in the event of an emergency. These people also have your permission to pick your child up from cheer clinic during the cheer clinic day. Name of person Relationship Telephone Current Health Condition Below check any current health condition that may require attention during the camp day. Allergies (be specific) Food Allergies Medication Allergies Bee Sting or Insect Bite Allergies Yes No Hemophilia: Yes No Asthma Yes No Seizures Yes No Cancer Yes No Diabetes Yes No Hearing Problems Yes No Hearing Aids Yes No Glasses Yes No Contacts Yes No Vision problems (be specific) Heart problems (be specific) Physical disability (be specific) Respiratory (be specific) Other (be specific) List all medications and dosages your child receives on a continual basis: I give permission for Jetz all star staff to administer any medications or creams. PARENT OR GUARDIAN SIGNATURE: DATE: PHYSICIAN INFORMATION My child's medical care is provided by: My child’s medical coverage is provided by: The Jetz All – Star organization has my permission, in an emergency when I cannot be contacted, to take my child to the nearest appropriate medical facility, and the facility and its medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child. PARENT OR GUARDIAN SIGNATURE: DATE:
In case of an emergency, the Jetz All –Star staff will contact 911.
Every attempt will be made to contact a parent, a guardian, or a designated emergency contact.
Child’s Name:
Date of Birth:
Parent / Guardian Contact Information:
Name: Telephone:
Address: Work Phone:
City: State: Zip Code:
Relation: Language:
Email:
Other Contact Information
Please list three people we may call if the parent(s) or guardian(s) cannot be reached in the event of an emergency. These people also have your permission to pick your child up from cheer clinic during the cheer clinic day.
Name of person Relationship Telephone
Current Health Condition
Below check any current health condition that may require attention during the camp day.
Allergies (be specific)
Food Allergies
Medication Allergies
Bee Sting or Insect Bite Allergies Yes No
Hemophilia: Yes No Asthma Yes No Seizures Yes No Cancer Yes No
Diabetes Yes No Hearing Problems Yes No Hearing Aids Yes No
Glasses Yes No Contacts Yes No Vision problems (be specific)
Heart problems (be specific)
Physical disability (be specific)
Respiratory (be specific)
Other (be specific)
List all medications and dosages your child receives on a continual basis:
I give permission for Jetz all star staff to administer any medications or creams.
PARENT OR GUARDIAN SIGNATURE: DATE:
PHYSICIAN INFORMATION
My child's medical care is provided by:
My child’s medical coverage is provided by:
The Jetz All – Star organization has my permission, in an emergency when I cannot be contacted, to take my child to the nearest appropriate medical facility, and the facility and its medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child.
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