Medical Emergency Form And Contact List printable pdf download

Medical Emergency Form And Contact List

Quebec Vipassana Centre

(Québec)

810, Côte Azélie, Notre-Dame-de-Bonsecours, Montebello

J0V 1L0

514 481-3504 • Fax : Registration 514 879-3437 •

Medical Emergency Form and Contact List

To be completed if you will not be staying at the meditation centre while your child is at the course:

CONSENT FOR MEDICAL TREATMENT

As the parent or legal guardian, I hereby give consent to the Meditation Centre (run by the Eastern

Canada Vipassana Foundation) to provide emergency medical care prescribed by a duly licensed

physician (MD)

for ______________________________________________________________________________

child’s name

This care may be given under whatever conditions are necessary to preserve the life, limb or

well-being of my dependent.

Signed __________________________________________ Date ____________________________

Home Phone _____________________________ Cell Phone _______________________________

Work Phone(s) _____________________________________________________________________

Alternative Persons Who May Be Called In An Emergency:

1) Name _____________________________________ Phone _______________________________

Relationship to you ________________________________________________________________

2) Name _____________________________________ Phone _______________________________

Relationship to you ________________________________________________________________

Child’s Physician: _____________________________ Phone ______________________________

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Medical Emergency Form And Contact List