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Emergency Contact Form
This information will be extremely important in the event of an accident or medical emergency.
In case your child suffer from any ailment or met with an any kind of accident, we will contact you or your near know as soon as possible.

Please fill out the form below. The above information is very useful.
- I have voluntarily provided the above contact information and authorized Southern Ohio Medical Center and its representatives to contact any of the above on my behalf in the event of an emergency.

Your Company Name

Address

Emergency Contact Form