Emergency Contact Name definition

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

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

• Describe way of contacting: Emergency Contact Name: Phone: GENERAL BACKGROUND Services are available to help you be safer and more independent in your household activities.

• Parent/Guardian Name Date (Last Name) (First Name)Home Phone # Cell Phone # Parents' Emergency Phone # Other Emergency Contact: (Name) Phone # PARENT/GUARDIAN SIGNATURE 805 EAST 3RD STREET 🞟 BROOKLYN, NY 11218 🞟 718-438-0913 🞟 Fax: 718-851-8626 🞟 camptashbar@gmail.comSummer Address 305 REVONAH HILL ROAD, LIBERTY, NY 12754🞟845-292-5790🞟Fax 845-292-5766 PAGE 2MEDICAL AND PRESCRIPTION DRUG INSURANCE INFORMATIONPlease make copies of your medical and prescription insurance cards and paste in the boxes below.

• Name: High School: Age (at time of event): Grade (circle one): 9 10 11 12 Emergency Contact Name: Phone: The above-named person is/was a student in good standing with my school.

• Name Grade Age Parents Name Mom Cell Phone Dad Cell Phone Address Email Address: Emergency Contact Name Other Than Parents Cell Phone Special Concerns In the event of an emergency, if I cannot be reached and with the judgment of the recreation staff members, hospital attention is necessary, I authorize recreation program staff members to call the Rescue Squad to take my child to an available hospital or physician.

• Name of Legal Guardian Name of Minor Signature of Legal Guardian Signature of Minor Address/Phone number of Legal Guardian Emergency Contact Name Phone number YOUTH INVOLVEMENT ON A HABITAT WORK SITE:Youth aged 16 and older may participate as a Paid Intern on a Habitat work site subject to the following conditions: US Department of Labor Regulations prevent anyone under the age of 16 from working on a construction site.

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. Address: Phone: (_ )_ Vehicle information (make, model, color, plate) Make Model Color Plate# * * * *Any additional vehicles that may use seasonal permit Max of 2 vehicles on site at one time. 3rd vehicle MUST obtain ‘3rd vehicle permit’ and park in Xxxxxx or beach parking lot.

Emergency Contact Name. Address: Relationship to You: Phone#: University shall maintain all health records and information about participants in compliance with all applicable HIPAA and FERPA laws and regulations.