Fillable City of Falls Church Recreation & Parks 2020 (City of Falls Church)

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City of Falls Church Recreation & Parks 2020 (City of Falls Church)

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The City of Falls Church Recreation & Parks 2020 (City of Falls Church) form is 1 page long and contains:

  • 1 signature
  • 3 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Falls Church

BROWSE CITY OF FALLS CHURCH (VA) FORMS

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City of Falls Church Recreation & Parks 2020 Emergency Information Form
Save file as Last Name, First Name and submit to: Recreation@fallschurchva.gov
Camper Name:
____________________________ ________________________ ____________________________
First Middle Last
Preferred Gender Pronouns:
He/Him/His She/Her/Hers They/Them/Theirs Other:
Language Spoken at Home:
Home Address:
City/State:
Primary Guardian:
Primary phone:
Employer:
Secondary Phone:
Secondary Guardian:
Primary phone:
Employer:
Secondary Phone:
Please list three, local emergency contacts if the parent/guardian cannot be reached:
Name:
Relation:
Phone:
Name:
Relation:
Phone:
Name:
Relation:
Phone:
Please list all persons authorized to pick up your child other than the parent/guardian:
Medical Information
Health Insurance Provider:
Child's Physician:
HMO Number (if applicable):
Physician's Telephone:
Yes No Does your child have any allergies? If so, please specify below.
Yes No Will your child need medication during camp? If so, please request a medication authorization form.
Yes No Are there any issues (fears, etc.) that may easily upset your child? If so, please specify below.
Yes No Does your child require special accommodations? If so, please specify below.
Additional notes:
I hereby DO / DO NOT (please check one) permit my child to sign him/herself out of camp without an adult.
The camp has my permission, in an emergency when I cannot be contacted, to take my child to the emergency room of the
nearest hospital. The hospital’s medical staff has my authorization to provide treatment which a physician deems necessary
for the well-being of my child.
PARENT/GUARDIAN SIGNATURE: _________________________________________ DATE: _______________
Click here to reset the camper specific fields on the form. Parent/Guardian, emergency contact, and medical information will not be affected by this reset function.
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City of Falls Church Recreation & Parks 2020 (City of Falls Church)

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Completed 3 August 2020

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