Emergency Medical Authorization
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1
2EMERGENCY MEDICAL AUTHORIZATION
Please PRINT and use BLACK ink.
Part 1
The purpose of this form is to authorize the provision of emergency treatment for chapter members in the unlikely event that
they become ill or injured while traveling with their advisor. It is imperative the following information be furnished so that
the member will be cared for properly.
The authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concur-
ring in the necessity for such surgery, are obtained prior to the performance of such surgery.
I, _______________________________ of _______________________________________________________________,
(Name)
(Address)
(City)
(State, Zip)
hereby give my consent for: (1) the administration of any emergency treatment deemed necessary by a licensed physician or
dentist, (2) the transfer to any hospital reasonably accessible, and (3) consent to release the medical information provided.
__________________________________________________
Date ________/________/________
(Member’s Signature)
(Month)
(Day)
(Year)
__________________________________________________
Date ________/________/________
(Parent’s or Guardian’s Signature if member is under 18 years of age)
(Month)
(Day)
(Year)
__________________________________________________
Parent’s or Guardian’s Phone (___)______________
(Parent’s or Guardian’s Name)
(Area)
__________________________________________________
Alternative Contact’s Phone (____)______________
(Alternative Contact’s Name)
(Area)
The following information is needed by any hospital or practitioner not having access to the member’s medical history:
Does the member have:
ANY ITEMS MARKED “YES” SHOULD BE
EXPLAINED BELOW
1. Any allergies
FOOD
______________YES
______________NO
MEDICATION
______________YES
______________NO
OTHER (insect, etc.)
______________YES
______________NO
2. Any health problems or physical disabilities
______________YES
______________NO
3. Any respiratory problems
______________YES
______________NO
4. Any diabetes
______________YES
______________NO
5. Any epilepsy
______________YES
______________NO
6. Any chronic disease
______________YES
______________NO
7. Any emotional or psychological problems
______________YES
______________NO
8. Any medication being taken at present
______________YES
______________NO
9. Any Glasses YES/NO , Contact Lenses YES/NO , Hearing Devices YES/NO worn?
If any of the above questions are marked “YES,” please explain. If taking medication, please give name, amount of
dosage, and time medication is taken.
____________________________________________________________________________________________________
10. Date of last tetanus booster: ________/________/________
(Month)
(Day)
(Year)
11. Does member have all required immunization shots?
______________YES
______________NO
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