Southern Cross Christian Co-op Southern Cross Christian Co-op
 

Medical Info - Family

indicates a required answer

Father's Medical Information

1. *

Father's First name:

2. *

Father's Last name:

3. *

Father's Birthdate:

4. 

Current Medications:

5. 

Allergies to Medications:

6. 

Other Serious Issues (e.g. food allergies):

Mother's Medical Information

7. *

Mother's First Name:

8. *

Mother's Last Name:

9. *

Mother's Birthdate:

10. 

Current Medications:

11. 

Allergies to Medications:

12. 

Other Serious Issues (e.g. food allergies):

13. *

Emergency contact name:
(In the event the parent present at Co-op is incapacitated)

14. *

Emergency contact phone number:

Hospital Preference Information
 

15. *

Hospital Name:

16. *

Hospital Address:

17. *

Hospital Phone Number:

Health Insurance Information

18. *

Insurance Company Name:

19. *

Contract Number:

20. *

Group Number:

Physician Information
The following liscensed physician is authorized to give urgent or emergency care to my child. In the event this physician cannot be reached, I give permission for another liscensed physician to treat me or my child.

21. *

Physician's Name:

22. *

Clinic Name & Address:

23. *

Clinic Phone Number:

An SCCC Board Member has my permission to call an ambulance to transport me or my child(ren) to the nearest medical facility for emergency medical treatment. I will be financially responsible for any expenses incurred.

By entering your name below you are signing this form electronically.

24. *

Mother's Full Name:

25. *

Date:

26. *

Father's Full Name:

27. *

Date: