ICUC Junior’s Club

Child Name

First Name

Last Name

Gender

Male

Female

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Name

First Name

Last Name

Email

Phone

(###)

###

####

Relationship to child

Emergency Contact Name

First Name

Last Name

Email 1

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Relationship to child

Please list three individuals, other than parent mentioned, who are permitted to pick up your child

Is you child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Yes

No

If you selected yes, explain