The following medical infomration is needed in the event of an accident. Please complete this form as accurately as possibel. This form will only be used to help the Red Wing Environmental Learning Center staff respond to an emergency.
Name *
Name
Primary Phone
Primary Phone
Birthdate
Birthdate
Address *
Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Parent or Guardian address if different
Parent or Guardian address if different
Parent or Guardian (2) home phone
Parent or Guardian (2) home phone
Parent or Guardian (2) cell phone
Parent or Guardian (2) cell phone
Insurance Phone Number
Insurance Phone Number
HAS/DOES THE PARTICIPANT (PLEASE EXPLAIN ANY YES ANSWERS BELOW):
Participant Name:
Has/does the participant
Please check the boxes that apply and describe below. Have you ever