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Request Membership for Southern Cross Christian Co-op (SCCC)
indicates a required answer
Father's Medical Information
Father's First name:
Father's Last name:
Father's Birthdate:
Current Medications:
Allergies to Medications:
Other Serious Issues (e.g. food allergies):
Mother's Medical Information
Mother's First Name:
Mother's Last Name:
Mother's Birthdate:
Emergency contact name: (In the event the parent present at Co-op is incapacitated)
Emergency contact phone number:
Hospital Preference Information
Hospital Name:
Hospital Address:
Hospital Phone Number:
Health Insurance Information
Insurance Company Name:
Contract Number:
Group Number:
Physician Information The following liscensed physician is authorized to give urgent or emergency care to my child. In the event this physician cannot be reached, I give permission for another liscensed physician to treat me or my child.
Physician's Name:
Clinic Name & Address:
Clinic Phone Number:
An SCCC Board Member has my permission to call an ambulance to transport me or my child(ren) to the nearest medical facility for emergency medical treatment. I will be financially responsible for any expenses incurred.
By entering your name below you are signing this form electronically.
Mother's Full Name:
Date:
Father's Full Name:
