complete and return this form to the Office of Continuing ... · Web view2012/11/12 · complete...
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COMPLETE AND RETURN THIS FORM TO THE OFFICE OF CONTINUING EDUCATION: Emergency Contact Form Emergency Contact Form Name of Camp Child is Registered To: ____________________________ Name of Child: ________________________________________________ Last First MI Sex: M or F Age: __________ DOB: ____________________ Primary Emergency Contact: Name: __________________________________ Relationship to Child: _________________________ Phone Number: ________________________________________ Secondary Number: _____________________ Secondary Emergency Contact: Name: __________________________________ Relationship to Child: _________________________ Phone Number: ___________________ ____________________ Secondary Number: _____________________ List any known drug allergies or other allergies (including type of reaction) which may affect the child’s ability to participate fully in the camp. Please use the back of this page if more space is needed. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________ Office of Continuing Education Pellegrino Hall 301~ Phone: 956.326.3068 ~ Fax: 956.326.2838 ~ Email: [email protected] Updated & Approved by OGC: 5/10/2012, KMC
Transcript of complete and return this form to the Office of Continuing ... · Web view2012/11/12 · complete...
complete and return this form to the Office of Continuing Education:
complete and return this form to the Office of Continuing Education:
Emergency Contact Form
Emergency Contact Form
Name of Camp Child is Registered To: ____________________________
Name of Child: ________________________________________________
Last FirstMI
Sex: M or FAge: __________DOB: ____________________
Primary Emergency Contact:
Name: __________________________________ Relationship to Child: _________________________
Phone Number: ________________________________________ Secondary Number: _____________________
Secondary Emergency Contact:
Name: __________________________________ Relationship to Child: _________________________
Phone Number: ___________________ ____________________ Secondary Number: _____________________
List any known drug allergies or other allergies (including type of reaction) which may affect the child’s ability to participate fully in the camp. Please use the back of this page if more space is needed.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List any medical condition(s) or medication(s) being taken which may affect the child’s ability to participate fully in the camp. Please use the back of this page if more space is needed.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I ___________________________________ (Print Name) hereby certify that the above history is complete to the best of my knowledge and I do hereby give permission for Texas A&M International University (TAMIU) Student Health Services provider(s), doctors, nurse practitioners, and nurses to perform examinations, diagnostic testing, and other procedures necessary to help maintain my child's health for as long as he/she is attending TAMIU camp programs. I understand and give consent for protected health information to be used to carry out treatment or for other health care.
__________________________________________________________________
Parent/Legal Guardian SignatureDate
Office of Continuing Education
Pellegrino Hall 301~ Phone: 956.326.3068 ~ Fax: 956.326.2838 ~ Email: [email protected]
Updated & Approved by OGC: 5/10/2012, KMC
