Emergency Contact/medical Consent Form
Download a blank fillable Emergency Contact/medical Consent Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Emergency Contact/medical Consent Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Emergency Contact/Medical
Consent Form
Organization __________________________________________________________________________
Date(s) of Activity _____________________________ Location of Activity ________________________
Student Information
Name (Last, First, MI) ______________________________________ Date of Birth _________________
Address ___________________________________________ Telephone (home) ___________________
City_______________________________________________ Telephone (work/other) _______________
State/Zip___________________________________________ Telephone (mobile) __________________
Emergency Contact (list at least one)
Contact #1
Contact #2
Name
____________________________
____________________________
Telephone
Home
____________________________
____________________________
Work
____________________________
____________________________
Mobile
____________________________
____________________________
Address
____________________________
____________________________
City/State/Zip
____________________________
____________________________
Relationship to Student
Spouse
Parent/Guardian
Spouse
Parent/Guardian
(circle one)
Relative
Friend
Relative
Friend
Medical Information (attach extra pages if necessary)
1. Describe all prescription medications or special medical care you require. If none, write NONE.
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Describe all medications to which you are allergic. If none, write NONE.
_____________________________________________________________________________________
_____________________________________________________________________________________
3. Describe all other allergies (including food) or special medical conditions. If none, write NONE.
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Provide Name, City and Telephone number to your physician.
_____________________________________________________________________________________
_____________________________________________________________________________________
5. Are you covered under a medical/hospitalization insurance plan? If no, write NONE. If yes,
provide the following information: ____________________________________________________
Insurance Company _________________________________
Policy Number ____________________
Name of Insured _______________________________________________________________________
Employer/Group Name__________________________________________________________________
In the event of a serious medical emergency, I authorize San Jacinto College, its employees, and/or other agents (collectively the
College) to secure medical transportation or treatment on my behalf. I understand that the College is not required to obtain medical
transportation or care for me. I understand that the College will attempt to contact one of the individuals I have designated as an
emergency contact. I authorize the College to release the information on this form to health care providers for the purpose of
securing health care services for me. I understand and agree that I am responsible for all expenses, fees, or costs incurred as a
result of the medical transportation or care secured for me by the College. I understand and agree that the College is not liable for
any injury or damages that may occur as a result of medical treatment that I may receive.
_________________________________________________________
_________________________
Student Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal