Emergency Medical Form - Stumptown Mennonite Church

Student's Name

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone

Date of Birth

Gender

Male

Female

School District

Name of Legal Guardian

Name(s) of Person with Whom the Student Resides

Permission to Contact Non-Custodial Parent (if applicable)

Yes

Phone of Non-Custodial Parent (if applicable)

Known Allergies

Health Concerns (asthma, diabetes, etc.)

Known Food Allergies

Current Medications

Name of Insurance Company

Insurance Policy Number

Authorized Contacts

An authorization of the provision of emergency treatment for students who become ill or injured while involved in a Youth Ministry function. PLEASE LIST ONLY THE NAMES OF THOSE WHO HAVE AUTHORITY TO MAKE DECISIONS IN AN EMERGENCY SITUATION INVOLVING THIS STUDENT. Please list the order in which you desire contact attempts to be made based on availability.

Primary Contact Name

Primary Contact Employer

Primary Contact Home Phone

Primary Contact Cell Phone

Primary Contact Work Phone

2nd Contact Name

2nd Contact Employer

2nd Contact Home Phone

2nd Contact Cell Phone

2nd Contact Work Phone

3rd Contact Name

3rd Contact Employer

3rd Contact Home Phone

3rd Contact Cell Phone

3rd Contact Work Phone

Consent

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for: 1) the administration of treatment deemed necessary by the preferred doctor indicated, or, in the event the designated, preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the student to any reasonable accessible hospital. This authorization does not cover major surgery unless the medical options of two other licenses physicians or dentists concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

Preferred Physician

Physician Phone

Preferred Dentist

Dentist Phone

Preferred Hospital

Typing your name here indicates I give consent for medical treatment

Date Signed