Emergency Medical Form
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2Office of Student Life
EMERGENCY MEDICAL FORM
PARTICIPANT INFORMATION
Name:
D.O.B./Age:
Address:
City
State
Zip Code
Primary Phone:
Secondary Phone:
EMERGENCY CONTACT INFORMATION
Name:
Relationship:
Phone:
Secondary Phone:
Name:
Relationship:
Phone:
Secondary Phone:
Name:
Relationship:
Phone:
Secondary Phone:
MEDICAL PROVIDER INFORMATION
Doctor:
Phone:
Fax:
Dentist:
Phone:
Fax:
Medical Specialist:
Phone:
Fax:
Preferred Hospital:
Phone:
Fax:
I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor,
or in the event the designated preferred practitioner is not available, by another licensed physician or dentist:
and (2) the transfer of the participant to 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 prior to performance of such surgery.
MEDICAL HISTORY
Facts concerning the participant’s medical history including allergies, medications being taken, and any
physical impairments to which a physician should be alerted:
Allergies to Medications/Other:
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Parent category: Medical