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Keep form up-to-date and give to EMS/fire/police in emergency Job Address: Directions: Phone Number: Childs Name: Birthdate GUARDIAN INFORMATION Title: Mr./Mrs./Ms. Name: Phone: ( ) and/or Title: Mr./Mrs./Ms. Name: Phone: ( ) MEDICAL HISTORY (Please check the following that apply) Asthma Diabetes Vision Problems Seizures Hemophilia Hearing Loss Respiratory Cardiovascular Bee Sting Allergy Digestion Urinary Kidney Physical limitations Allergies: Restricted activities: Presciption medication: Childrens Doctor: Phone: Health Insurance Company, Group Number, and ID Number: POISON HELP: 1-800-222-1222 SPECIAL INSTRUCTIONS: Bedtime Routine: Meals/Snacks: Discipline Techniques: AUTHORIZATION FOR EMERGENCY CARE If the parents/guardians named on this sheet cannot be reached at the time of an emergency, and if medical observation or treatment is urgent, I hereby authorize the child to be transported via ambulance to the most appropriate hospital..
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