Acadia First Nation Youth Center General
Information Sheets
Name of Child: ___________________ D.O.B _________________
Address: _____________________________________________________________
Parents Names: (Mother)
_____________ Telephone: __________________
Work: __________________
Cell:
__________________
(Father) _________________
Telephone: _________________
Work: __________________
Cell: __________________
In a case, which you cannot be reached, please list
2 emergency contact names and numbers:
(1). ________________________ Telephone: _______________________
(2). ________________________ Telephone: _______________________
…………………………………………………………………………………………....................................……
Medical
Information
Please list any allergies that your
child has:
(1) __________________________ (2) _________________________
(3) _________________________ (4) _________________________
Health Card Number:
_________________ Expiry Date: _________________
(Please fill in this number, it is very important for
us to have on file in case there is and emergency)
Family Doctor: __________________ Telephone: ____________________
Please indicate any information that would help us understand
your child better: Example: restrictions
of exercises, limitations, do they have asthma or any other health problems, etc.
________________________________
________________________________
________________________________
Parent/Guardian Signature:
___________________ Date:
__________________
Consent to Medical Treatment
Should an incident arise whereby my child requires medial
attention, the person or persons working at Youth Center shall attempt to contact me in order to obtain my consent regarding
all medical treatment be carried out on my child. Should it not be possible to
contact me, I give the person or persons working at the Youth Center consent to any and all medical treatment for my child
recommended as being necessary by a physician.
Parent/Guardian Names and Address and Numbers:
______________________________
______________________________
I _______________(Parent’s name), give consent
to medical treatment for my child, ________________ (child’s name) if an incident should arise in or during a Youth
Center activity. Should it not be possible to contact me, permission is granted
to the Youth Center’s Employees and/or to the above person or persons, to follow through with any and all medical procedures
for my child recommended by a physician.
Dated this _______ day of ________, year of, _________.
Signed ____________________ (Parent/Guardian)
