2021 Emergency Medical Authorization

2021 Emergency Medical Authorization Form

Participant Name
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Date of birth
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Grade of participant (A for adult)
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Address
Street*
City/Suburb
State*
Zip/Post Code*
Country*
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Participant cell phone
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Participant home phone
Parent/Guardian Name
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Parent/Guardian Phone
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Additional Parent/Guardian Name
Additional Parent/Guardian Phone
Please list one relative or friend who will assume temporary responsibility for your ill/injured child if you can not be reached:

Relative or Friend Emergency Contact Name
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Relative or Friend Emergency Contact Phone
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In the event that reasonable attempts to contact parents at phone numbers provided are unsuccessful, I hereby give my consent for:

1) the transfer of my child to a hospital,

2) the administration of treatment deemed necessary by a licensed physician or dentist.

This authorization does not include major surgery unless the medical opinions of two licensed physicians or dentists concur in the necessity for such surgery and are obtained prior to performing such surgery.

Parent/Guardian Signature (or Participant if age 18 or older)
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Date
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Submit