Emergency Information Sheet printable pdf download

Lake Washington United Methodist Church

Kirkland, Washington 98033

Emergency Information Sheet

Note: This information sheet is to be filled out by the parent or legal guardian of each chorister. It will be taken on each activity in which the

choir participates. Should an emergency arise, the information that you have listed will be used in any medical treatment required.

MEDICAL CARE

NAME OF CHORISTER ________________________________________ DATE OF BIRTH______________________

HOME ADDRESS_____________________________________________PHONE_____________________________

In case of medical emergency, I understand that every effort will be made to contact me and the emergency contact person.

In the event neither of us can be reached, I hereby authorize and request the adult counselor(s) to secure emergency medical

and/or hospital care for________________________________ (Name of chorister).

I hereby give permission to the physician selected by the counselor(s) to hospitalize, secure proper treatment for, and/or to

order injection, anesthesia, or surgery for the above-named chorister. Information the medical team may need is included in

the Health Information section below.

I accept full financial responsibility for any medical services required, including prescription and non-prescription drugs and

other supplies, on behalf of my child.

DATE __________________ SIGNATURE OF PARENT/GUARDIAN _______________________________________________

Parent/Guardian Name(s) ________________________________________________ Home Phone___________________

Parent Phone(s) _____________________________ Additional Parent Phone(s)___________________________________

Family Physician____________________________ Phone_________________

Emergency Contact Person_________________________________

Home Phone_________________ Work Phone_________________ Cell Phone_________________

HEALTH INFORMATION (May be shared with other leaders and medical personnel as needed.)

A physical examination is recommended if there has been none within the past year. Currently healthy? __________ If no,

please indicate health problem(s): _______________________________________________________________________

____________________________________________________________________________________________________

Immunization/latest Booster Dates: D.P.T.________ Tetanus________ Polio_________ Smallpox_______

Other: ______________________________________________________________________________________________

Allergies, Conditions (Y/N): Hayfever___ Asthma___ Convulsion___ Fainting___Poison Ivy___ Penicillin___

Sulfa___ Bee Sting___ Other___ (Describe):________________________________________________________________

If Yes to any of the above, please indicate treatment, past or present, and preventative and emergency measures which

should be taken: _____________________________________________________________________________________

___________________________________________________________________________________________________

Medications: Please list any medications which are being taken at present, including dosage, frequency and any other

pertinent information:

____________________________________________________________________________________________________

Additional Information: _________________________________________________________________________________

Emergency Information Sheet