FAMILY INSURANCE INFORMATION 25/26

indicates a required answer

Please fill in your Family and Medical Insurance Information below. If you need to add more children, you will need to add a new form. You do not need to fill in all of the Family Information again, just the Family Name at the top, then proceed to #22.

1. *	Family Name

2.	Home Phone Number

3.	Father's Name

4.	Father's Cell Number

5.	Father's Work Number

6.	Father's Email Address

7.	Mother's Name

8.	Mother's Cell Number

9.	Mother's Work Number

10.	Mother's Email Address

11.	Home Address, City, Zip

12.	Emergency Contact #1 and Relationship

13.

Emergency Contact #1 Phone Number

Home/Cell/Work

14.	Emergency Contact #2 and Relationship

15.

Emergency Contact #2 Phone Number

Home/Cell/Work

16.	Medical Insurance Company

17.	Member's Name

18.	Member's Phone Number

19.	Member's Birthdate

20.	Member's Social Security Number

21.	Policy number

Child Information - Completed by Parent or Guardian

** Social Security number is optional. Please note that some hospitals WILL NOT treat without it **

22.	Child #1 Name

23.	Child #1 Birthdate

24.	Child #1 Cell Phone Number

25.	Child #1 Social Security Number

26.	Child #1 Allergies (if none, put N/A)

27.	Child #1 Medications (if none, put N/A)

28.	Child #1 Chronic Conditions, e.g. diabetes, epilepsy (if none, put N/A)

29.	Child #1 Doctor

30.	Child #1 Doctor's Phone Number

31.	Additional facts concerning Child #1's medical history, including any physical impairments to which a physican should be alerted:

32.	Child #2 Name

33.	Child #2 Birthdate

34.	Child #2 Cell Phone Number

35.	Child #2 Social Security Number

36.	Child #2 Allergies (if none, put N/A)

37.	Child #2 Medications (if none, put N/A)

38.	Child #2 Chronic Conditions e.g. epilepsy, diabetes (if none, put N/A)

39.	Child #2 Doctor

40.	Child #2 Doctor's Phone Number

41.	Additional facts concerning Child #2's medical history, including any physical impairments to which a physician should be alerted.