Youth Alive - Emergency Medical Form (EMF)
Please complete a separate form for each student.
Child's First Name *
Child's Last Name *
Date Of Birth (DOB) *
MM
/
DD
/
YYYY
Mother's Name *
Mother's Phone Number *
Father's Name *
Father's Phone Number *
Street Address
City
Zip
Name of an additional person who can be contacted in an emergency
What is that person's mobile phone number?
Child's Allergies
Please list any allergies that your child has.
Child's Health Concerns
Please list any medical issues that the CBC staff should be aware of.
Child's Physician
Physician's Phone Number
Child's Dentist
Dentist's Phone Number
Preferred Hospital
Hospital Phone Number
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.
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