Washington Pavilion Emergency Contact Form
This form is required prior to participating in Washington Pavilion educational programming.
Child's Information
Student First Name *
Your answer
Student Last Name *
Your answer
Gender
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Information
First Name *
Your answer
Last Name *
Your answer
Email *
Your answer
Primary Emergency Phone *
xxx-xxx-xxxx
Your answer
Secondary Phone *
Your answer
Health and Emergency Information
I do hereby give my consent to Washington Pavilion Management Inc. for my child(ren) to receive medical or surgical aid as may be necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when a parent or guardian cannot be reached. Consent is also given for Washington Pavilion Management Inc. or a duly appointed representative to transport my child for emergency medical treatment if a parent or guardian cannot be reached.
Preferred Emergency Treatment Facility *
Your answer
Allergies/Medical Conditions *
Your answer
Permission for Self Check-Out
Only for ages 11+
Self Check-Out *
Media Release
I give permission for the Washington Pavilion to use my child's name, photographs and interviews for future publications, promotional materials (print and online) or educational materials. *
Signature
Please initial below.
By initialing below, I certify that all information provided on this form is accurate. *
Your answer
Comments
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