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Emergency Medical Form

Child's First Name

Child's Last Name

Address

Parent Email

Child's Date Of Birth

Grade *

Kindergarden

1st

2nd

3rd

4th

5th

Height

Weight

Emergency Contact #1 - Name

Emergency Contact #1 - Phone

Emergency Contact #2 - Name

Emergency Contact #2 - Phone

Information for health care providers in case of emergency. Please check all that apply.

Heart Condition? *

Yes

No

If so, what is the usual treatment?

Asthma? *

Yes

No

If so, what is the usual treatment?

Allergy? *

Yes

No

If so, what is the usual treatment?

Bleeding Disorders? *

Yes

No

If so, what is the usual treatment?

Diabetes? *

Yes

No

If so, what is the usual treatment?

Is there anything we should know about your child's behavior so we can help him/her be successful in our program?

Thanks for submitting!

Download Waiver

Please download the waiver, read and sign, then return to Kerri or Alicia in person or to info@4peakskids.com

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