Hand in Hand

Hand in Hand
3860 Middle Road
Bettendorf, Iowa 52722
email us: info@handinhandqc.org

Phone: (563) 332-8010   Fax: (563) 332-7396
Parental Emergency Consent Form
This consent form will be in effect for one year from the date submitted.
Child's Name:*     Date of Birth:*
Parents/Guardians/Custodians with whom the child resides:
Name:*    Relationship to Child:*
Primary email address:*
Address:*
City:*    State:*    Zip:*
Home Phone:*    Cell Phone:
Employer:*    Work Phone:*
Name:    Relationship to Child:
Address:
City:    State:    Zip:
Home Phone:    Cell Phone:
Employer:    Work Phone:
Persons to contact in case of an emergency if parents are unavailable:
Name:*    Relationship to Child:*
Home Phone:*    Cell Phone:
Name:    Relationship to Child:
Home Phone:    Cell Phone:
In the event that my child would require medical or surgical care while I'm unable to be reached, I hereby give consent for medical care to the following doctor:
Child's Doctor:*     Phone:*
Address:
City:    State:    Zip:
Hospital:*
In the event that my child would require dental care or dental surgical care while I'm unable to be reached, I hereby give consent for dental care to the following dentist:
Child's Dentist:*     Phone:*
Address:
City:    State:    Zip:
Hospital:
Insurance and Medical Information
Insurance Company:*     Policy #:*
Allergies:*
Current Medications:*
Last Tetanus:*     Religious Preference:*

           * - Mandatory Fields.

Hand-in-Hand is a non-profit organization that assists families with special needs. We exist to expand the capabilities, confidence and quality of life for children and young adults of all abilities by providing programs designed to encourage fun, learning and social interaction in a positive environment.