Authorization For Emergency Medical Attention printable pdf download

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

In the event that we cannot be reached at a time of illness or accident, we authorize the Jersey Village Baptist Church Director of

Weekday Ministries or her Designate to take:

My Child

_______________________________________________

To Dr. _____________________________________________________________ Phone (_____) ____________________________

Address _____________________________________________________________________ Zip ____________________

Or Dr. _____________________________________________________________ Phone (_____) ____________________________

Address _____________________________________________________________________ Zip ____________________

If neither of the above Doctors can be reached, permission is granted for another licensed Doctor to be called.

Another adult who can be contacted in case of an emergency when parents cannot be reached_________________________________

(Relationship to your child) __________________________________________________ Phone (_____) ______________________

Address __________________________________________________________________________ Zip _______________________

Signatures of BOTH parents are required.

Father’s Signature ________________________________ Date ________________

Mother’s Signature ________________________________ Date ________________

NOTE: Parents should authorize the Doctor to accept any call from the Director or her Designate for medical information or for

emergency medical care.

INSURANCE INFORMATION:

Do you have hospitalization?

Yes

Mother’s Name ____________________________________ Father’s Name ______________________________________________

Home Address _____________________________________________ City _____________________ State _______ Zip _________

Phone (_____) _______________________

Father’s Business Address ___________________________________ City ___________________ State _______ Zip __________

Father’s Business Phone (_____) ______________________

Insurance Co. ______________________________________________________________ Phone (_____) _____________________

Group # ______________________ Cert. # _________________________ Soc. Sec # ______________________________________

Mother’s Business Address ___________________________________ City __________________ State ________ Zip __________

Mother’s Business Phone (_____) _____________________

Insurance Co._______________________________________________________________ Phone (_____) _____________________

Group # ______________________ Cert. # _________________________ Soc. Sec # ______________________________________

Continued on the Back

Authorization For Emergency Medical Attention