Emergency Medical Authorization Please enable JavaScript in your browser to complete this form.Should my Child(ren)s (see below) suffer an injury or illness while in the care of Kids University and the facility is unable to contact me immediately, it shall be authorized to secure medical attention and care for the child as may be necessary. I (We) agree to keep the facility informed of changes in telephone numbers, etc. where I (We) may be reached. I (We) shall assume responsibility for payment of services . The facility agrees to keep me informed of any incidents requiring professional medical attention involving my child *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #2 NameFirstLastDate of Birth MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #3 Name FirstLastDate of Birth MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Care Provider *Primary Care Provider Phone *Medical Coverage: Policy Holder Name *FirstLastInsurance Company and Policy # *Known Medical Conditions (i.e. diabetic, asthma, drug or food allergies) *Name of Parent/Legal Guardian *FirstLastEmergency Phone Number *Signature of Parent/GuardianClear SignatureSubmit