EMERGENCY INFORMATION MOPS—2011-2012 Mother’s Full Legal Name: _________________________________________________________________________________ LAST

FIRST

MIDDLE

IF MY CHILD IS ILL OR HAS AN EMERGENCY AND I CANNOT BE REACHED, PLEASE CALL AND RELEASE MY CHILD TO:

Address: _________________________________________________ City: ________________________ Zip: ______________ Phone #: ________________________________________ Email: __________________________________________________

Name: _________________________________ Home Phone: ____________________________ Cell Phone: ______________________________

Child #1

Address: ________________________________

Name: _____________________________________________________________________ DOB: ______________ Gender: M / F LAST

FIRST

Medical Information Physician’s Name: __________________________________ Address: _________________________________________________ Physician’s Phone #: ________________ Hospital Preference: __________________________ Date of last tetanus shot: ________ Insurance Provider: ______________________________________ Medical ID #: ________________________________________ Child has no known health problems

List prescribed medication(s): ______________________________________

Child has the following conditions (circle all that apply):

ASTHMA

EPILEPSY

FAINTING SPELLS

DIABETES

Please explain anything circled: ______________________________________________________________________________________

Child has a physical condition which limits participation in: classroom activities

HYPERACTIVE MIGRAINES

HEART CONDITION ALLERGIES

physical activities

Please explain anything else we should know about your child’s health: _____________________________________________________________________________________________

Child #2 Name: _____________________________________________________________________ DOB: ______________ Gender: M / F FIRST

MIDDLE

Medical Information Physician’s Name: __________________________________ Address: _________________________________________________ Physician’s Phone #: ________________ Hospital Preference: __________________________ Date of last tetanus shot: ________ Insurance Provider: ______________________________________ Medical ID #: ________________________________________ Child has no known health problems

In the event that I cannot be reached in an emergency during MOPS, I hereby give my permission to the physician or dentist selected by Redwood Chapel to hospitalize, to secure proper treatment, and / or to offer an injection or anesthesia. Signed: _________________________________ Parent Date: __________________

OTHER

_______________________________________________________________________________________________________________________________________________________

LAST

City: ______________________ Zip: _________

MIDDLE

I give Redwood Chapel / CV MOPS the absolute right and permission to publish in print, electronic (including internet use), or video format, the likeness of my child, without further consideration or approval from myself. I also waive any right to royalties or other compensation arising from or related to the use of said images by Redwood Chapel / CV MOPS. I release the photographer, their offices, employees, agents, and designess from any liability for any violation of any personal proprietary right I may have in connection with such use. Signed: _________________________________ Parent Date: __________________

List prescribed medication(s): ______________________________________

Child has the following conditions (circle all that apply):

ASTHMA

EPILEPSY

FAINTING SPELLS

DIABETES

Please explain anything circled: ______________________________________________________________________________________

Child has a physical condition which limits participation in: classroom activities

HYPERACTIVE MIGRAINES

HEART CONDITION ALLERGIES

OTHER

physical activities

FOR MOPS GROUP USE ONLY: Date received: __________________________

Please explain anything else we should know about your child’s health: _____________________________________________________________________________________________

Discussion Group: _______________________

_______________________________________________________________________________________________________________________________________________________

Date registered for MOPS Int’l _____________

EMERGENCY INFORMATION MOPS—2011-2012 Mother’s Name: ______________________________________________________________________________________________________________ Child #3 Name: _____________________________________________________________________ DOB: ______________ Gender: M / F LAST

FIRST

MIDDLE

Medical Information Physician’s Name: __________________________________ Address: _________________________________________________ Physician’s Phone #: ________________ Hospital Preference: __________________________ Date of last tetanus shot: ________ Insurance Provider: ______________________________________ Medical ID #: ________________________________________ Child has no known health problems

List prescribed medication(s): ______________________________________

Child has the following conditions (circle all that apply):

ASTHMA

EPILEPSY

FAINTING SPELLS

DIABETES

Please explain anything circled: ______________________________________________________________________________________

Child has a physical condition which limits participation in: classroom activities

HYPERACTIVE MIGRAINES

HEART CONDITION ALLERGIES

OTHER

physical activities

Please explain anything else we should know about your child’s health: _____________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Child #4 Name: _____________________________________________________________________ DOB: ______________ Gender: M / F LAST

FIRST

MIDDLE

Medical Information Physician’s Name: __________________________________ Address: _________________________________________________ Physician’s Phone #: ________________ Hospital Preference: __________________________ Date of last tetanus shot: ________ Insurance Provider: ______________________________________ Medical ID #: ________________________________________ Child has no known health problems

List prescribed medication(s): ______________________________________

Child has the following conditions (circle all that apply):

ASTHMA

EPILEPSY

FAINTING SPELLS

DIABETES

Please explain anything circled: ______________________________________________________________________________________

Child has a physical condition which limits participation in: classroom activities

HYPERACTIVE MIGRAINES

HEART CONDITION ALLERGIES

OTHER

physical activities

Please explain anything else we should know about your child’s health: _____________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________