forms

Photograph & Video Release Form

Please list at least two people to whom the child may be released to if the parent or guardian is not available.

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Primary Contact *

Primary Home Phone

Alternate Phone

Primary Relationship

Primary Cell Phone

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Secondary Contact *

Secondary Home Phone

Secondary Alternate

Secondary Relationship

Secondary Cell Phone

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Additional Contact (One) *

Additional Home Phone (One)

Additional Alternate (One)

Additional Relationship (One)

Additional Cell Phone (One)

Physician Name *

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Physician Phone

Dentist Name *

Dentist Address

Address Line 1

Address Line 2

City

State

Zip Code

Dentist Phone

Hospital Affiliate Name & Location

Child’s Insurance Plan

Subscriber/Primary on the Plan

Subscriber ID Number

Is there any additional information that you would like to share with us about your child?

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Parent/ Guardian E-Signature (One) *

Parent/ Guardian E-Signature (Two) *

Date (Parent/Guardian)(One)

Date (Parent/Guardian)(Two)