Young Preschool Registration Packet - YMCA of Metro Atlanta

Medical Care and Emergency Contact Information
Child’s Name:__________________________________________ Birth date:________
Address_________________________________________________________________
Mother’s Name_____________________________ Phone_______________________
Father’s Name______________________________ Phone_______________________
Alternate Emergency Contact 1)______________________________________________
Alternate Emergency Contact 2)______________________________________________
Child’s Physician:_________________________________________________________
Family Physician__________________________________________________________
Known Allergies of Child (medicine, food, etc.)_________________________________
________________________________________________________________________
Describe past serious illnesses or hospitalization, with dates________________________
________________________________________________________________________
________________________________________________________________________
Health Insurance: Company______________________ Policy#___________________
________________________________________________________________________
NOTARIZED EMERGENCY MEDICAL TREATMENT CONSENT
I hereby give the Andrew and Walter Young Family YMCA Preschool permission to
provide first aid care for my child. In the event I cannot be reached, I hereby authorize the
Andrew and Walter Young Family YMCA Preschool to transport my child to the
emergency room of the hospital/s listed below. And I hereby grant my consent for the
hospital and its medical staff to provide my child with emergency medical treatment which
a physician deems necessary ( including anesthesia). If I have not specified any hospital/s
below, my child may be taken to and cared for at the nearest hospital. I agree to accept
financial responsibility for all medical expenses incurred.
Hospital//s:_____________________________________________________________
________________________ _________
_________________________ _______
Parent/Guardian Date Parent/Guardian Date
State of Georgia
County of_________________________________
The foregoing CONSENT was acknowledged before me this _________ day of _________________, 20____.
Notary_________________________________
(Notary Seal)
My commission expires_________________