Emergency Medical Treatment Authorization printable pdf download

EMERGENCY MEDICAL TREATMENT AUTHORIZATION

Athlete’s Legal Name:____________________________________________________________ Grade:_____________________

Athlete’s Date of Birth: ____________________________________________Date of last tetanus shot: ____________________

My child is allergic to the following medications: ________________________________________________________________

My child has the following allergies: __________________________________________________________________________

Please identify any serious injuries or illnesses your child has had: ___________________________________________________

Alternate family member/friend to contact in case of emergency:

Name:___________________________________________________ Phone: ________________________________________

Primary Care Doctor Name: ______________________________________________Phone: _____________________________

Primary Insurance Company:_________________________________________ Policy #:________________________________

Insurance Company Address:____________________________________________________________________________________

I give permission and authorize the officers, board members, program directors, coaches or other representatives of Crew Boosters of

Winter Park, Inc., as agent(s) for the undersigned, to consent to any x-ray examination, and the anesthetic, medical or surgical diagnosis

or treatment, and hospital care which is deemed advisable by, and is to be rendered under general or special supervision of any physician

and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or

treatment is rendered at the office of said physician or said hospital. It is understood that this authorization is given in advance of any

specific diagnosis, treatment or agent(s) to give specific consent to any and all such diagnoses, treatment or hospital care which the

physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable. I further agree

to hold said agents and their respective employees harmless in the administration of such assistance. I hereby authorize any hospital

which provided treatment to the above named minor to surrender physical custody of such minor to my above named agent(s) upon

completion of treatment. These authorizations will remain in effect for one (1) year from the date hereof unless revoked in writing and

delivered to said agent(s).

I hereby acknowledge and certify that I have read the emergency medical treatment document, that I understand and agree with its terms,

and that I make the following written declaration under Section 92.525, Florida Statutes: “Under penalties of perjury, I declare that I

have read the foregoing Emergency Medical Treatment Authorization and that the facts stated in it are true.” I agree to be bound by its

terms and I have reviewed and explained the notice with my child.

I understand, authorize, and consent to the release of my child’s or ward’s protected health information to my child’s or ward’s coach,

assistant coach, and to any adult chaperone who is transporting my child or ward or who is assigned to oversee my child or ward at any

Crew Boosters of Winter Park, Inc. event or trip of any kind on a strictly limited and need to know basis to protect the health and safety

of my child or ward and the other student rowers who participate in rowing programs through Crew Boosters of Winter Park, Inc.

Printed Name of Participant: _______________________________________________

Signature:____________________________________________________________ Date:_____________________________

Permanent Address:______________________________________________________________________________________

If Participant is under 18, parent/guardian signature is required below.

Printed Name of Parent/Legal Guardian: ______________________________________________________________________

Signature:_____________________________________________________________________________ Date: ____________

Relationship:______________________________________________________________ Phone:________________________

Emergency Medical Treatment Authorization