ChildGuard ID Information Form

Make payable to:

SARA, PO Box 607, Midlothian, TX. 76065

3 Photo ID cards: $25.00 - each additional card $5.00 - Shipping & Handling $7.00 per order

Texas Residents must add 6.75% Texas Sales Tax

INCLUDE 1 PHOTO OF CHILD WITH ORDER

Child Full name:

 

Child Nickname:

 

Hair/Eye Color:

 

Height/Weight:

 

Date of Birth:

 

Native Language:

 

Parent/Guardian name/s:

 

Address:

 

City/State/Zip:

 

Home Phone:

 

Work Phone:

 

Insurance Carrier:

 

Insurance Phone:

 

Policy #:

 

Physician Name & Ph #:

 

Medical Conditions:

 

 

Medications:

 

 

Allergies:

 

Disabilities:

 

Blood Products Allowed:

NO              YES            (circle)

Parent/Guardian Signature for medical release: