Emergency Information Form printable pdf download

Presbyterian Church of Palm Harbor Youth Ministry

EMERGENCY INFORMATION FORM 2016

EMERGENCY INFORMATION:

Student Name: ________________________________________________________________________________

Address: _____________________________________________________________________________________

_____________________________________________________________________________________________

Primary Cell Number ____________________________ Date of Birth: __________________________ Male/Female

PARENTS/GUARDIANS: EACH TO BE LISTED SEPARATELY:

Name Relationship _____________________________________________________________________________

Address Home and Cell Phone___________________________________________________________________________

Employer Office Phone__________________________________________________________________________

Cell Phone or Other ________________________________________________________________________

Name Relationship_____________________________________________________________________________

Address Home and Cell Phone __________________________________________________________________________

Employer Office Phone _________________________________________________________________________

Cell Phone or Other ________________________________________________________________________

IN THE EVENT PARENTS/GUARDIANS CANNOT BE REACHED, CHILD MAY BE RELEASED TO:

(Minimum of two contacts)

Name Relationship Daytime #s ___________________________________________________________________

Should none of the above contacts be available, I hereby authorize the administration of any treatment

deemed necessary by the following:

Preferred Physician/phone: _______________________________________________________________________

In the event of a life-threatening emergency or unavailability of preferred doctors, I authorize another

licensed physician and/or the transfer of my child to the following hospital or any hospital reasonably

accessible:

Preferred Hospital: _____________________________________________________________________________

This authorization does not cover major surgery unless the medical opinion of two licensed physicians,

concurring the necessity for such surgery, is obtained prior to the performance of the surgery. All doctors

should be alerted to the information on this form concerning my child’s medical history (allergies,

medications, physical impairments, etc.)

Parent/Guardian Signature ________________________________________________ Date: _________________

Form continued on reverse

Emergency Information Form