EMERGENCY INFORMATION

for all participants

Effective: November, 2005-December, 2006

 

Please fill this out completely.  This form should travel with your group.

 

Name:                                                                                                    Age:            

 

Home Address:                                                                                                                     

 

City:                                                                State:                         Zip:                            

 

Date of Birth:            /          /          Home Phone:                                                             

 

   We (I) authorize an adult, in whose care the minor/adult has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor/adult under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. 

   The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for me/my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

 

 

Insurance Co.                                                 Policy #                                             

 

Address:                                                         City:                                        State:            

 

Hospital Insurance:   Yes    No       

EMERGENCY NUMBERS

Doctor:                                                                                   Number:                                

Parent/Guardian:                                                                  Number:                                

Other:                                     Relationship:                          Number:                    

Are there any allergies, medications or special medical problems which we need to be aware of in regard to your child?  (Including motion sickness)  Please list:

                                                                                                                                               

                                                                                                                                               

 

 

                                                                                    Notary____________________

Signature of Parent or Legal Guardian

or adult participant                                                  Date______________________