Allergy/Medical/Special Needs Form 2021/22

We are so glad to have your child and your family be a part of the life and programs at Emmanuel. This form is intended to share information among the volunteers and staff that interact with your child. This information is important and is used carefully, but it isn't intended to be kept confidential. Please be specific about how to best care for your child. Keep in mind that our volunteers are not professionally trained, but want your child to feel that they are in a safe and welcoming environment. You only need to do this once each year - we will do our best to share info between the various programs.

Child Name

Please tell us about any allergies, medical conditions, learning disabilities, attention difficulties or special needs that we should know about.

Does this child have an EPI pen? Yes No

If yes, where is it located when he or she is in programs at Emmanuel?

What situations or actions put your child at risk or cause them to feel uncomfortable or overwhelmed?

Please give suggestions about how we can respond:

What (if anything) do you want visible on your child's name badge (worn during programming)? Not all programs use name badges. Limit of 30 characters:

Emergency Contact Info
(only one adult's info is required)

Parent #1 Name

This address will receive a confirmation email

Mobile Phone

Home Phone

Parent #2 Name

Mobile Phone

Please share this info with the following programs: The Woods (Sunday School) Youth Ministry Awana Day Camp Bloom Childcare Vertical Basketball League other

Contact information will be used by Emmanuel Barrie for communication regarding this and other events, ministries and programs. Please see our Privacy Policy for more information.

Description

Please fill out this form and click submit.

Allergy/Medical/Special Needs Form 2021/22

Description

Please Fix the Following