Emergency Treatment Consent and Emergency Information

Fighting Irish Rugby Football Club

2003

 

I.                   EMERGENCY TREATMENT CONSENT

To all parents:

Since the malpractice question has come to the forefront, many hospitals and doctors will not treat a child without the parents’ consent (unless it is a matter of life or death).  It is requested that you complete the information below so that if your child requires a visit to the hospital while under the supervision of the Fighting Irish Rugby Football club coaching staff, this will allow the hospital to treat the injury.

 

II.                EMERGENCY INFORMATION

 

Name: ____________________________________

 

Age: _____           Date of Birth: _____/_____/_____

 

Parent’s name: __________________________________________

Father’s SS# _____________                              Mother’s SS#: _________________

Work Address: ____________________            Work address: ____________________

Work Phone:    ____________                            Work phone:   _________________

 

Home Address: ____________________________________________________

Home Phone:    (     )_______________

 

 

Alternate Contact

 

Name: __________________________     Phone: (     ) ______________                   

Relationship: ______________

 

Insurance

 

Insurance Name: ________________________

Name of Insured: ________________________

Policy and group numbers: _________________

 

ALLERGIES: _________________________

MEDICATIONS: ______________________

 

 

Consent to authorize treatment:

 

Parent’s Signature: ______________________________

Date: _____________