Emergency Medical Form printable pdf download

Emergency Medical Form

Please complete ONE form per membership (Family, Couple or Single)*

If members do not have medical problems, allergies, or conditions, you may use one form for all

members listed below. If a member has a medical condition that should be known, please make

additional copies of this form for each member with an exception.

Adult Member Names:

List All Children:

______________________________________

_______________________________________________________

Last, first

______________________________________

__________________________________________________________

Last, first

_________________________________________________________________________________

Primary address:

Home telephone: ___________________________________________________________________________________

work phone #1:__________________________

work phone #2:_______________________________________

cell phone #1:__________________________

cell phone #2:_______________________________________

**Other contact (name, relationship and phone number) _____________________________________________

**To enable members to authorize emergency treatment for family members who become ill or injured

while under club authority, when emergency contacts above cannot be reached.

PART I or PART II MUST BE COMPLETED

PART I TO GRANT CONSENT

In the event reasonable attempts to contact all emergency contacts listed above have been

unsuccessful, I hereby give my consent for (1)the administration of any treatment deemed necessary

by:

Dr. ___________________________________________(preferred physician),

___________________________________________(phone number)

or by Dr.______________________________________(preferred dentist),

______________________________________(phone number)

Or in the event the designated preferred practitioner is not available, by

another licensed physician or dentist; and (2) the transfer of the member to

_______________________________________________(preferred hospital) or 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 before the

surgery is performed.

Please indicate facts regarding a members medical history including allergies, medications being

taken, and any physical impairments to which a physician should be alerted: ______________________

__________________________________________________________________________________________________

___________________________________

__________________________

_________________

Member Signature

Date

PART II REFUSAL TO CONSENT

(DO NOT COMPLETE PART II IF YOU COMPLETED PART 1)

I DO NOT give my consent for emergency medical treatment of my family member. In the event of

I wish the club authorities to take no action

illness or injury requiring emergency treatment,

or to:_________________________________________________________________________

___________________________________________

_______________________

Member Signature

Date

Emergency Medical Form

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