Youth Alive - Emergency Medical Form (EMF)
Please complete a separate form for each student.
Child's First Name *
Your answer
Child's Last Name *
Your answer
Date Of Birth (DOB) *
MM
/
DD
/
YYYY
Mother's Name *
Your answer
Mother's Phone Number *
Your answer
Father's Name *
Your answer
Father's Phone Number *
Your answer
Street Address
Your answer
City
Your answer
Zip
Your answer
Name of an additional person who can be contacted in an emergency
Your answer
What is that person's mobile phone number?
Your answer
Child's Allergies
Please list any allergies that your child has.
Your answer
Child's Health Concerns
Please list any medical issues that the CBC staff should be aware of.
Your answer
Child's Physician
Your answer
Physician's Phone Number
Your answer
Child's Dentist
Your answer
Dentist's Phone Number
Your answer
Preferred Hospital
Your answer
Hospital Phone Number
Your answer
Please check to affirm that you have read and understand the following statement:
Please type your full name in the space below indicating your consent for medical treatment based on the statement above and indicating completion of this Emergency Medical Form.
Your answer
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