Emergency Medical Information Form Lombard Gospel Chapel Student’s Name  _____________________________________  Date of Birth _____________________________ Parents/Guardians  ____________________________________________________________________________ Home Address  ______________________________________________________________________________ Home Phone  (        ) __________________________  Cell Phone (         ) _______________________________ If I/we cannot be reached in case of emergency, contact the following: Name __________________________  Phone _________________________  Relationship _________________ Name __________________________  Phone _________________________  Relationship _________________ Family Physician ________________________________  Phone _______________________________________ Address  ___________________________________________________________________________________ Affiliated Hospital(s)  __________________________________________________________________________ Information on allergies, medications, and any physical limitations:  _____________________________________ ____________________________________________________________________________________________ ___________________________________________________________________________________________ Insurance Information:  Please list insurance company, phone number, and account number.  (If you have an insurance ID card, you may copy both sides and staple it to this form.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ Parent or Guardian: In the event that I, or the other contact person(s) cannot be reached in an emergency,  I give my consent for Lombard Gospel Chapel to arrange for emergency medical/dental care and treatment necessary to preserve the health of my child.  I authorize the rendering of such care, by members of the hospital staff, as deemed necessary in their professional judgment. ________________________________________________          _______________________________ Parent/Guardian Signature                                                                                            Date