BCHW Jr. Division

    ENROLLMENT FORM:

   MEDICAL INFORMATION AND TREATMENT AUTHORIZATION

NAME                                                                                                

 DOB                                                               
 

ADDRESS                                                                                           CITY                                                    

STATE                         ZIP CODE                                                                                                                    

PARENT                                                                                             HOME

PHONE                                              
 

PARENT                                                                                             WORK PHONE                                    

ADDRESS                                                                                           CITY                                                    

STATE                         ZIP CODE                                                                                                                    

Emergency Contact: (in the event you can not be reached)                                                                                   

NAME                                                 PHONE                                   RELATION                                          

NAME                                                 PHONE                                   RELATION                                          

FAMILY DOCTOR                                                     HOSPITAL                                                                

ADDRESS                                                                   CITY                                       STATE                        

ALLERGIES                                                                                                                                                                                                                                                        

ILLNESSES                                                                                                                                                                                                                                                         

MEDICATIONS                                                                                                            

                                                                                                                                       

I                                                                           PARENTS/LEGAL GUARDIANS  

OF                                                    ALLOW REASONABLE AND NECESSARY MEDICAL CARE FOR MY CHILD TO BE AUTHORIZED IN THE EVENT I CAN¬íT BE REACHED. THIS MAY INCLUDE BUT IS NOT LIMITED TO TRANSPORTATION, EMS CARE, ER TREATMENT AND SURGERY GIVEN BY A COMPETENT, LICENSED MEDICAL PROFESSIONAL.   

X                                                                X