Wharton/Rockaway/Mine Hill Recreation Commission

2016 EMERGENCY CARD

ACTIVITY Volleyball

PARTICIPANT ______

(NAME) (ADDRESS) (PHONE)

FATHER ______

(NAME) (PLACE OF BUSINESS) (PHONE)

MOTHER ______

(NAME) (PLACE OF BUSINESS) (PHONE) \

FAMILY ______

PHYSICIAN (NAME) (ADDRESS) (PHONE)

If a parent cannot be contacted – A neighbor or relative in this immediate area who may be contacted in the event of an emergency or illness.

  1. ______

(NAME) (ADDRESS) (PHONE)

  1. ______

(NAME) (ADDRESS) (PHONE)

ALLERGIES: YES NO If yes, please list ______

In the event that none of the above persons can be contacted; I hereby give my permission for my

Child (name) ______to be transported to:

(Please Check One) St. Clares – Denville or St. Clares - Dover

for medical treatment by the family physician and /or hospital physician.

______/______/______

Date Signed (Signature of Parent or Guardian)

For Rockaway Residents Only

Registration # ______

Activity ______

Date ______

Signed ______