Emergency Contact Name definition

Emergency Contact Name. Relationship: Phone: Participant's Signature (if 18 or older) :

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Emergency Contact Name. Street Address: City: State: Zip: Phone Number:

Emergency Contact Name. Ph#: Relationship: Referral Source:

Examples of Emergency Contact Name in a sentence

• Emergency Contact Name: Emergency Contact Phone Number: Please initial one of the following statements: to allow Family Service Bureau of Newark, permission to send me a Follow-up Discharge Letter/Survey.

• CONTACT INFORMATION Senior Name: Date of Birth: Senior Cell Phone: Senior Email: Address: Parent/Guardian Name(s): Parent/Guardian Phone(s): Parent/Guardian Email: Emergency Contact Name: Relationship to Student: Phone Number(s) Medications: Chronic Illnesses/Allergies: Date of Last Tetanus Shot: Insurance Provider: Emergency Care Plan (“ECP”).

• Parent / Carer’s Signature: Date: (Please state relationship to child if not parent): Print Name: Email: Emergency Contact Name: Relationship to Child: Tel No: Late Collection Contact: Relationship to Child: Tel No: This form should be completed by the young person supported by their parent/carer, where appropriate.

• In the case of emergency, the Service Provider should contact: Emergency Contact Name: [EMERGENCY CONTACT NAME] Phone Number: [EMERGENCY CONTACT PHONE NUMBER] Relation: [EMERGENCY CONTACT RELATION] Emergency Contact Name: [EMERGENCY CONTACT NAME] Phone Number: [EMERGENCY CONTACT PHONE NUMBER] Relation: [EMERGENCY CONTACT RELATION] EMERGENCY PROTOCOL.

• Signature of Legal Guardian and/or Parent of Participant Date Emergency Contact Name and Relationship to Participant Phone Number Participant's Insurance I.D. number and insurance carrier, carrier address and phone number: ASSUMPTION OF RISK, WAIVER OF LIABILITY AND INDEMNIFICATION AGREEMENT This Agreement must be completed by the Participant in order to participate in activities taking place at the University of Utah’s School of Dance at the Marriott Center for Dance.

More Definitions of Emergency Contact Name

Emergency Contact Name. Phone: I would like to receive an update while boarding: □ by email □ by text □ emergency only Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting Canned food: Dry food: Treats: TREATMENT: Please list any services that you would like to have done during your cat’s stay. (Additional fees apply.) □ Brush sessions □ Playtime sessions □ Nail trim □ Other (list below) If an exam is performed, please have the doctor contact □ call me □ email me □ text me, or □ I prefer to wait and discuss exam findings at pick up.

Emergency Contact Name. Relationship: Home Phone: Cell Phone: Work Phone: Permission to Call: Yes No Restrictions? Relationship to Client: Date of Birth: Email: Phone: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Relationship to Client: Date of Birth: Email: Phone: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Relationship to Client: Date of Birth: Email: Phone: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Relationship to Client: Date of Birth: Email: Phone: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Relationship to Client: Date of Birth: Email: Phone: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Care and Counseling is a non-profit organization and is able to provide subsidized counseling due to the contributions of our many funders. In order to secure funding, it is often necessary to provide aggregate household income data for our client base, which illustrates our financial need. This figure is to include all sources of income -- i.e. salary, child support, maintenance, investment income, housing allowances. Please check the appropriate range for your gross family income and the number of members living in or financially dependent on your household. Information provided to funders is only given in aggregate form and individual client information is not released.

Emergency Contact Name. Physical Address: City: Postal Code: Relationship to Child: Home Phone Number: Cell Phone Number: Place of Work: Work Address: Work Phone Number:

Emergency Contact Name. Physical Address: City: Postal Code: Relationship to Child: Home Phone Number: Cell Phone Number: Place of Work: Work Address: Work Phone Number: Name: Phone Number: Alternate Phone Number: Name: Phone Number: Alternate Phone Number: Name: Phone Number: Alternate Phone Number: Person(s) to whom child may NOT be released. Name(s), description. Are there any legal custodial issues? YES NO If yes, please explain and supply relevant legal documents. If yes, please refer to Parenting Order Acknowledgement. I, , acknowledge that, should there be a parenting order in place regarding my child , it is my responsibility to provide a copy of this order to the YMCA Before & After School Care Program. I also understand that I am responsible for providing any updates to this order should any changes occur. If I do not provide a copy of this parenting order, I understand that my child will be allowed to leave the program in the company of any parent/ guardian listed within their file. The YMCA Before & After School Care Program will not undertake any responsibility for the child upon releasing the child to a parent/ guardian in accordance with program procedures and licensing regulations. Staff Use Only: Was a parenting order provided? Staff Initials: YES NO Parent/Guardian Signature: Parent/Guardian Signature: Date: Date: Grade: Names and ages of other children in your family: 1: 3:

Emergency Contact Name. Relationship: Phone:

Emergency Contact Name. Phone: Address: Physician’s Name: Phone: Hospital of Choice:

Emergency Contact Name. Phone: Guardian/Legal Representative: Billing Information (if ▇▇▇▇ is to be sent to a different location than address listed above): Please note: If you exceed the stated amount of units, your signature on the timesheet(s) serves as authorization. You will be invoiced for all hours recorded on the signed timesheet. Fees: Deposit and Billing Information I understand: (Initial each item)