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Youth emergency contact form

Above The Influence Network

Emergency Contact Form

Participant Information:

Full Name

Date of Birth

Phone

Country/Region

Address

City

Zip / Postal code

Parent/Guardian Information:

Name

Relationship

Phone Number

Alternate Phone Number

Emergency Contact:

Other than parent/guardian

Name

Relationship

Phone Number

Alternate Phone Number

Medical Information

Allergies

Medications

Medical Conditions

Insurance Provider

Policy Number

In the event of an emergency, I authorize the Above the Influence Network staff to contact the emergency contacts listed above and to secure emergency medical treatment for my child if needed. I understand that I will be responsible for any medical expenses incurred.

Parent / Guardian Signature

Date

Group Hug

JOIN THE MOVEMENT

Together, we can create a future where every young person has the opportunity to thrive. Whether you’re looking to volunteer, donate, or simply stay informed, your support makes all the difference. Let’s rise above and make a lasting impact, one community at a time.

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