Emergency Medical Authorization Form
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PARTICIPANT INFORMATION
Participants Last Name *
Participants First Name *
Participants Middle Name *
Participants Date of Birth (Do Not Put Today's Date) *
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Participants T-Shirt Size

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Home Address *
City *
State *
Zip Code *
School Attended *
RESIDENTIAL PARENT GUARDIAN INFORMATION
Mother's First and Last Name *
Mother's Daytime Phone *
Mother's Cell Phone *
Father's First and Last Name *
Father's Daytime Phone *
Father's Cell Phone *
Other Name(s)
Other Daytime Phone
Other Cell Phone
Primary Contact's Email Address *
MEDICAL INFORMATION

I hereby give consent for the following medical care providers and local hospital to be called.

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Doctor Name *
Doctor Phone *
Dentist Name *
Dentist Phone *
Medical Specialist Name (If None, Type "NONE") *
Medical Specialist Phone (If None, Type "NONE") *
CONSENT

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. 

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. 

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Facts concerning the child’s medical history including allergies, medication being taken, and any physical impairments to which a physician should be alerted: 

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REFUSAL TO CONSENT

I do NOT give my consent for emergency treatment of my child.  

In the event of illness or injury requiring emergency treatment, I wish the Recreation Department authorities to take the following action:   

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Your child will ONLY be released to the following people unless the Recreation Center Management is otherwise notified in advance.

PARENT/GUARDIAN TO BE CONTACTED FIRST

Name of Parent/Guardian To Be Contacted First

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Daytime Phone of Parent/Guardian To Be Contacted First

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Cell Phone of Parent/Guardian To Be Contacted First

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Parent/Guardian To Be Contacted First Relationship To Child

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SECOND PERSON TO CONTACT

Name of Parent/Guardian To Be Contacted Second

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Daytime Phone of Parent/Guardian To Be Contacted Second

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Cell Phone of Parent/Guardian To Be Contacted Second

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Parent/Guardian To Be Contacted Second Relationship To Child

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THIRD PERSON TO CONTACT

Name of Parent/Guardian To Be Contacted Third

Daytime Phone of Parent/Guardian To Be Contacted Third

Cell Phone of Parent/Guardian To Be Contacted Third

Parent/Guardian To Be Contacted Third Relationship To Child 

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