Emergency Contact and Health Card – Redeemer Renaissance

Please complete all sections below and click SUBMIT when finished. If you need additional time to complete the form you can select 'Save and Resume Later' and send a secure link to finish at a later time.

Last Name

First Name

Birthdate

Home Address

Phone

Parent 1 Name

Parent 1 Phone 1

Parent 1 Phone 1 Type

Parent 1 Email 1 *

Parent 1 Phone 2

Parent 1 Phone 2 Type

Parent 1 Email 2

Employer Name & Location

Parent 2 Name

Parent 2 Phone 1

Parent 2 Phone 1 Type

Parent 2 Email 1

Parent 2 Phone 2

Parent 2 Phone 2 Type

Parent 2 Email 2

Employer Name & Location

Other Caregiver

Phone

Emergency Contacts and Release

If it is necessary to contact parents during program hours, staff will first call the parents at work, then the child’s home. If neither is available, the Redeemer Renaissance After-School Program is authorized to release my child to any of the following persons: (Contacts need to be within 15 minutes of the school.) At least two persons, other than parents above, are required.

Name

Relationship

Phone 1

Emergency 1 Phone 1 Type

Phone 2

Emergency 1 Phone 2 Type

Emergency Name 2

Emergency Relationship 2

Emergency 2 Phone 1

Emergency 2 Phone 1 Type

Emergency 2 Phone 2

Emergency 2 Phone 2 Type

Emergency Name 3

Emergency Relationship 3

Emergency 3 Phone 1

Emergency 3 Phone 1 Type

Emergency 3 Phone 2

Emergency 3 Phone 2 Type

Out of Area Contacts for use during a Community Emergency (at least 2 hours away)

Name

Relationship

Phone 1

Out of Area Contact 1 Phone 1

Phone 2

Out of Area Contact 1 Phone 2

Name

Relationship

Phone 1

Out of Area Contact 2 Phone 1

Phone 2

Out of Area Contact 2 Phone 2

Current Health/Medical Information

Please CHECK any health conditions that the Redeemer Renaissance After-School Program staff needs to be aware of or may require attention during program hours.

If none, please check here

No allergies or other health conditions to report

Allergies

Be specific and complete Action Plan

Foods (ex: Peanut, Dairy, Wheat)

Bee Stings / Insect Bites

Medicines

Other

Asthma

Physical Limitations

Seizures

Other

Heart Problem

Respiratory

Vision Problems

List all medications and dosages your child receives on a continual basis:

Physician Information

My child’s medical care is provided by:

Name of Doctor

Location

Phone

My child’s medical coverage is provided by:

Health Insurance Co./HMO

Policy No.

Location

Phone

Redeemer Renaissance After-School Program staff has my permission, in an emergency, to secure appropriate medical care for my child. The medical staff has my authorization to provide necessary medical treatment for the well-being of my child.

Parent Signature

Clear Signature

Date

Updated

Save and Resume Later

After-School

Preschool

Camps

Resources

Parents

Staff

Other

Allergies

Other Health Conditions

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After-School Program

Preschool

Camps