360° Studio Emergency Form Address:​____​ ​Str

 360° Studio Emergency Form Learner Name:​
___________________________________________ ​
Date of Birth:​
___________________ Last First ​
Parent/Guardian​
:​
__________________________________ Ph:_____________________________________ Last First cell work/home Parent/Guardian:​
__________________________________ Ph:_____________________________________ ​
​
Last First cell work/home Main Email Address: ______________________________________________________________________________ Address:​
____​
______________________________________________________________________ ​
Street City State Zip Code Primary Emergency Contact Name:​
_______________________________________________________ ​
Last First Relationship:​
​
_____________________________________________________________________________ Home Phone:​
_______________________ ​
Cell: _
​_________________________ ​
Work:​
_​
_____________________ Secondary Emergency Contact Name:​
______​
________________________________________________ ​
Last First Relationship: ​
_____________________________________________________________________________________ Home Phone:​
______________________ ​
Cell: ​
__________________________ ​
Work: ​
_________________________ Preferred Local Hospital: ​
___________________________________________________________________________ Insurance Information: Company:​
______________________________________________ ​
Policy #:​
_________________________________ Sibling(s) in 360? Y or N Name/grade(s):​
___________________________________________________________ Allergies: Y or N Epi­pen dependant? Y or N List specific allergens​
: Special physical/emotional health conditions? Y or N Comments on back​
­ include any special medical or personal information you would want an emergency care provider to know – or special contact information: I authorize all medical and surgical treatment, x­rays, laboratory, anesthesia, and other medical/hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver ​
only​
applies in the event that neither parent/guardian can be reached by phone in the case of an emergency. Signature: ​
_____________________________________________________​
Date: ​
____________________________