Youth Emergency Medical Info
Please fill out this form and click submit.
Youth Name
*
Doctor's Name
*
Doctor Phone Number
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Preferred Hospital
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Special instructions for any and all treatment deemed necessary by the attending physician
*
Insurance Provider
*
Insurance Policy #
*
Emergency Contact
*
Emergency Contact Phone #
*
Emergency Contact Email
*
This address will receive a confirmation email
Emergency Contact Address
*
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Food Allergies or Other Allergies We Should Be Aware Of: Please list any known food allergies (e.g., nuts, dairy, gluten) or other allergies (e.g., insect stings, medications, latex) that we should be informed about to ensure your youth's safety and comfort.
*
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Description
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