-1Emergency Contact Information:

Name of Student: ______________________________________________

Name of Primary Parent/Guardian: ________________________________

Phone number(s) primary adult can be reached at during teen center hours:

_________________________________________________

Additional adult to contact in an emergency: ________________________

relationship to student: ____________________

Please advise of any medical, psychological/social or learning needs our staff should be aware of (food allergies, depression, ADHD, reading difficulties etc.)

Please list any medications the youth is taking:

Insurance Policy # _______________________________

Doctor and phone____________________ _______________________

I agree to allow Hedding UMC staff to provide basic first aid care. I also agree to allow HUMC staff to call for Emergency Medical care if necessary. I understand that they will make every effort to contact me in such a situation.

_____________________________ __________

Signature of Parent/Guardian date