After
School
Child
Care

Summer
Camp

Spring
Break
Camp

Forms
Bear River Recreation and Parks District
Print, Fill Out and Mail to: BRRPD 10042 Wolf Rd., Suite B,  PMB #11  Grass Valley, CA  95949
 
After-School Child Care / Spring Break & Summer Camps
Emergency Medical Information Form
Child's Name: ___________________ Age: ______ Date of Birth: ___________
Gender _________
Address: _________________________ Date of Tetanus Shot: ______________
City: _______________ Zip: _________
Home Phone: _____________________ List of Allergies:___________________
Cell Phone: _______________________     ______________________________
Mother/Guardian: __________________     ______________________________
    Daytime phone: _________________     ______________________________
Father/Guardian: __________________    
    Daytime phone: _________________ Current Medications: _______________
Family Physician: __________________     ______________________________
    Phone: ________________________     ______________________________
Insurance Co: _____________________     ______________________________
    Policy No: ______________________
Other contact? ____________________ Additional Comments: ______________
    Phone: ________________________     ______________________________

Parental or Guardian Consent for Daycare staff
In the event of an emergency, when the daycare staff believes medical attention may be required, I/We grant permission to the daycare staff to call for an ambulance and/or to give consent to any medical diagnosis or treatment by a licensed physician.
Parent/Guardian Signature _________________________________________
Parent/Guardian Signature _________________________________________
Updated August, 2008