Emergency Medical Authorization Form For Teens Under 19
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Emergency Medical Authorization Form for Teens
Under 19
STUDENT’S NAME________________________________________________________
BIRTHDAY__________________
Purpose: This form enables parents to authorize the provision for emergency treatment for children who
become ill or injured while at a youth event. Consent to seek such treatment is granted specifically to
official adult representatives and chaperones of St. Benedict Church, and if needed, to be evaluated,
diagnosed, treated, and/or medicated in accordance with standard medical practice by licensed medical
personnel.
I relieve St. Benedict, the adult leaders, Ministry, and the Archdiocese of Anchorage from all responsibility
and consequences that may arise as the result of this treatment.
I will not hold the St. Benedict, chaperones, or representatives associated with the event responsible in the
event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling such
treatment.
TO GRANT CONSENT
NAME OF PARENT OR
GUARDIAN______________________________________________________________________
HOME
ADDRESS_____________________________________________________________________________
______________________________________________________________________________________
HOME TELEPHONE NUMBER________________________________________________
FATHER’S WORK PLACE_____________________________________ PHONE #______________
MOTHER’S WORK PLACE____________________________________ PHONE #______________
REGULAR PHYSICIAN_______________________________________ PHONE #______________
In the event that reasonable attempts to contact the above named have been unsuccessful, I hereby
give my consent for any treatment deemed necessary for my child named on this form by medical
personnel at the nearest medical facility.
SIGNATURE OF PARENT OR GUARDIAN_____________________________________________
DATE___________
FAMILY INSURANCE COMPANY_________________________________________________
POLICY
#________________________________________________________________________________
If the parents cannot be reached, the alternate person to notify in the event of injury or illness is:
ALTERNATE CONTACT PERSON________________________________________________ PHONE
#_______________
STUDENT’S MOST RECENT MEDICAL HISTORY:
ALLERGIES______________________________________________________________________
MEDICATION BEING TAKEN________________________________________________________
PHYSICAL IMPAIRMENTS_______________________________________________________
VACCINATIONS OR BOOSTER SHOTS IN THE PAST YEAR_____________________________
SERIOUS ILLNESS OR ACCIDENTS IN THE PAST YEAR________________________________
OTHER PERTINENT INFORMATION
______________________________________________________________________
This form will be in the possession of the youth minister or other leaders at all events throughout the year.
You don’t need to fill out another one until the fall of 2012.
If there are any changes to any of the information above, it will be your responsibility to resubmit a form
with the correct information to Bob McMorrow before the event.
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