Child Travel Consent Form Clean

to Medications, Food): Prescription Medications: Date of Last Tetanus Injection/Booster: Child s Medical Care and Insurance Information Physician/Pediatrician: Dentist/Orthodontist: Phone Number: Phone Number: Preferred Medical Facility: Insurance Company: Policy/Group Number: Policy Holder: Parent/Guardian s Information Parent s/Guardian s Name: Address: Phone Number (H): Phone Number (W): Phone Number (C): Email: Parent s/Guardian s Name: Address: Phone Number (H): Phone Number (C): Phone Number (W): Email: Emergency Contact Person s Information Emergency Contact s Name: Phone Number (H): Phone Number (W): Phone Number (C): Email: Alternative Emergency Contact Person s Information Emergency Contact s Name: Phone Number (H): Phone Number (W): Phone Number (C): Email: WITNESS SIGNATURES I hereby acknowledge that the foregoing Child Travel Consent was signed by and in my presence..