Parent/Guardian #1 Contact Information
Parent/Guardian #2 Contact Information
Emergency Contact Information
Member Medical Information
IN CASE OF EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME. IN THE EVENT THAT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE HOSPITAL AND ATTENDING PHYSICIAN SELECTED BY BLESSED GIRLS TO TAKE ANY NECESSARY ACTION, INCLUDING SURGERY, ANESTHESIA, OR INJECTIONS, THAT IS IN THE BEST INTEREST OF MY CHILD.
MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGED CHILD CARE
As a parent/guardian of the above participating child, I certify the he/she is in good physical health, has no special needs, and may participating in all of the activities of the Blessed Girl Program, except as noted above.