Emergency Medical Authorization Form for Teens Under 19
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
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_____________________________________________
FAMILY INSURANCE COMPANY_________________________________________________
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:
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.