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MCHD begins COVID 19 vaccines for children 6 months - 5 years Monday, June 27, 2022

Medical Seatbelt Safety Day Signup Form

  • First Name: *

  • Last Name: *

  • Phone Number: *

  • Male / Female:

  • Child's Name (If Desired):

  • Do you want your diagnosis on the outside of the cover?:

  • If Yes, What if your diagnosis?:

  • Additional Information (As needed) such as a color or pattern (if we have something to match).:

  • The following will be used to complete the medical information form inside of the medical seatbelt cover. If you choose to not complete this electronically, you can complete this information the day of the event which is slower. The choice is completely yours:

  • Year of Birth: *

  • Parent or Guardian name and phone number(if applicable):

  • Emergency Contact Name and Phone Number (if applicable):

  • Emergency Contact Name and Phone Number #2 (if applicable):

  • I am an organ donor:

  • Preferred Hospital (based on medical severity):

  • Current Medical Diagnosis: *

  • Allergies: *

  • Relevant Health History: *

  • Current Medications (names of medications only): *

* = Required