2012 Super Summer Emergency Contact Form


  • Instructions To Reach Parent/Guardian During Super Summer Hours


  • Name, Address, Daytime Phone #

  • Name, Address, Daytime Phone #

  • Pediatrician or Source of Health Care


  • Name, Address, Daytime Phone #

  • Emergency Contact Person(s)


  • Name, Address, Daytime Phone #

  • Name, Address, Daytime Phone #

  • Please list allergies or medical conditions of which the staff should be aware.

  • Medical Emergency Treatment


    I hereby give my permission for the Super Summer staff of New Colony Baptist Church to administer basic first aid and/or CPR to my child named above and/or take my child named above, to a hospital for medical attention when I cannot be reached, or when a delay could be dangerous to my child’s health.