Guardian & Contacts

Check boxes or use short answers. Skip what does not apply; "not sure" is okay.

Parent or Guardian

First name *

Last name *

Relationship to child *

Phone *

Email *

Street address

City

State

ZIP

Preferred contact method

Phone callText messageEmail

OK to leave a voicemail?

YesNo

Other Parent or Guardian (if applicable)

Name

Relationship to child

Phone

Emergency Contact

Name

Relationship to child

Phone

Medical Decision-Making & Custody

Who has authority to make medical decisions for this child?

Any custody or consent documents the office should review?

YesNoNot sure

[Prototype note: document uploads are not available. You may describe relevant details in the field above.]