Computers for Youth Foundation, Inc.

(“CFY”)
Student Software Team (“SST”)

Emergency Contact and Medical Information for a Child/

Contacto de emergencia y información medico

M F
Child’s Name/Nombre de hijo/a Date of Birth/Fecha de nacimiento Sex/Sex
o

Parent’s/Guardian’s Name/Nombre de pariente o guardian Parent’s/Guardian’s Name/Nombre de pariente o guardian

([       ]) ([       ]) ([       ]) ([       ])

Home Phone/Número de Work Phone/Número de Home Phone/Número de Work Phone/Número de trabajo
casa trabajo casa

Address/Dirección Address/Dirección

City/Ciudad, ST/Estado ZIP Code/Codigo postal City/Ciudad, ST/Estado ZIP Code/Codigo postal

Alternative Emergency Contacts/Contacto de emergencia secundario/a

Primary Emergency Contact/Contacto de emergencia Secondary Emergency Contact/ Contacto de emergencia secundario/a
primario/a
([       ]) ([       ]) ([       ]) ([       ])
Home Phone/Número de Work Phone/Número de Home Phone/Número de Work Phone/Número de trabajo
casa trabajo casa

Address/Dirección Address/Dirección

City/Ciudad, ST/Estado ZIP Code/Codigo postal City/Ciudad, ST/Estado ZIP Code/Codigo postal

Relationship to Child/Relación al niño/a Relationship to Child/Relación al niño/a

Medical Information/Información Medico

Physician’s Name/Nombre de Medico/a Phone Number/Número de teléfono

Insurance Company/Compañia de seguro médico Policy Number/Número de póliza

Allergies (including food and medicine)/Any Special Health Considerations/Any Medications Taken Regularly
*Please note that CFY cannot administer any regularly-taken medications to your child.
I authorize CFY to obtain immediate medical attention for my child in the case of an emergency, and I authorize all medical and surgical
treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the
attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the
event that neither parent/guardian can be reached in the case of an emergency.

Parent’s/Guardian’s Signature/Firma de pariente o guardian Date/Fecha

I give permission for my child to take public transportation for CFY SST activities and attend CFY SST field trips around the New York
City area. I release CFY and its officers, directors, employees, agents, successors and assigns from liability in case of accident, casualty
and/or event which might occur during activities related to CFY and SST. I confirm that I have listed above all of my child’s allergies,
special health considerations, medications, and medical issues/problems above, to the best of my knowledge.

Parent’s/Guardian’s Signature/Firma de pariente o guardian Date/Fecha

Witness Signature/Firma de testigo Date/Fecha