Emergency Contact/Permission Form

 

 

My child _______________________________has permission to permission to participate in the:

 

Or

 

 

In case of emergency contact: _______________________________________________

            at  (phone) __________________     (cell) ___________________

 

Alternate emergency contact: _______________________________________________

            at  (phone) __________________     (cell) ___________________

            Relation to child: _________________________________________

 

Physician’s name: ______________________________________________

Physician’s phone number: _______________________________________

Insurance Company: ____________________________________________

Policy Number: ________________________________________________

 

Is participant currently under the care of a physician or psychologist? __________

If yes please Explain:_____________________________________________________

 

Does participant suffer from any health disorder, condition or allergy:  _______________

________________________________________________________________________

 

Is participant currently on any medication?______

Name of medication: ______________________________________________________

 

Please indicate and explain any other information that you believe might be useful to the adult-in-charge or to emergency personnel or a physician in the event of an emergency.  Also, please indicate if there are any restrictions on participant’s activity. ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

 

This health history is correct to the best of my knowledge, and participant has permission to engage in all activities, except as noted above.  In the event that the contact listed above cannot be reached in the event of an emergency, I hereby give permission to the physician, selected by the adult-in-charge, to hospitalize, secure proper anesthesia, order medication or perform emergency procedures for participant.

 

 

Signature ______________________________________________  Date ____________

                              (Parent/legal guardian/adult participant)

Event

 

 

Who:

 

What:

 

Where:

 

When:

 

Departure/Start Time:

                                   

Return/Stop time:

 

Meeting Place:

 

Cost:

 

What to Bring: 

 

Method of travel:

 

Adult(s) in charge:

 

Emergency contact: