Emergency Contact Form | Amerileagues

Amerileagues Emergency Contact Information Form

All campers are REQUIRED to have an Emergency Contact form filled out before being allowed to attend our camps. This information will be extremely important in the event of an accident or medical emergency. Please be sure to sign and date this form.

Camper First Name *

Camper Last Name *

Birth Date *

Parent/Guardian Name *

Cell Phone *

Alt Phone

Parent Email Address

completed form will be sent to this email address

Address *

Address 1

Address 2

City

State

ZIP code

Contact Name *

Contact Relationship *

relationship of this contact to the camper

Contact Address *

Address 1

Address 2

City

State

ZIP code

Cell Phone *

Alt Phone

Contact Name

Contact Relationship

relationship of this contact to the camper

Contact Address *

Address 1

Address 2

City

State

ZIP code

Cell Phone

Alt Phone

Hospital/Clinic Preference *

Physican Name *

Physician Phone *

Insurance Company *

Policy # *

Comments

include any special medical or personal information you would want an emergency care provider to know – or special contact information

Parent Guardian Signature

Another Form? *

would you like to fill out another Emergency Contact Form for another child?

MEDICAL INFORMATION

EMERGENCY CONTACT #1

CAMPER INFORMATION

EMERGENCY CONTACT #2

Leave this field blank