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City of Puyallup Emergency Information & Consent Child’s Home Cell Mother’s Father’s Emergency Contacts If parents can’t be reached who should be the next contacted? Contact 1 Relation to Phone Phone Contact 2 Relation to Phone Phone Family Medical Information Family Physician’s Physician’s Phone Serious Medical I/We hereby grant consent to any and all health care providers designated by Puyallup Parks and Recreation to provide my child (Name) any necessary medical care as a result of any injury/illness. The consent includes Firs Aid and transportation to/from health care providers. Date Parent Name Signature Date Parent Name Signature