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Emergency Care
Acct #
Swimmer's Name
*
First
Last
Swimmer's Date of Birth
*
MM slash DD slash YYYY
Parent/Guardian 1 Name
*
First
Last
Parent/Guardian 1 Phone
*
Parent/Guardian 2 Name
First
Last
Parent/Guardian 2 Phone
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Physician Address and Phone
*
List known allergies to medications:
List known allergies to insect bites, bee stings, etc.:
List medications taken on a daily basis:
Agreement and Approval
*
I authorize a member of the HH Pool staff to seek medical assistance for my child when I or my emergency contact cannot be contacted.
Checking this box and clicking submit serves as a legal signature for this electronic form. The form will be date stamped and kept on file for the 2019 pool season.
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