Youth Alive - Emergency Medical Form (EMF)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete a separate form for each student.

Child's First Name *

Child's Last Name *

Date Of Birth (DOB) *

YYYY

Mother's Name *

Mother's Phone Number *

Father's Name *

Father's Phone Number *

Street Address

City

Zip

Name of an additional person who can be contacted in an emergency

What is that person's mobile phone number?

Child's Allergies

Please list any allergies that your child has.

Child's Health Concerns

Please list any medical issues that the CBC staff should be aware of.

Child's Physician

Physician's Phone Number

Child's Dentist

Dentist's Phone Number

Preferred Hospital

Hospital Phone Number

Please check to affirm that you have read and understand the following statement:

In the event reasonable attempts to contact me at the above phone numbers have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event my preferred doctor is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital or doctor’s office reasonably accessible via authorized youth chaperone’s vehicle or ambulance. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Please type your full name in the space below indicating your consent for medical treatment based on the statement above and indicating completion of this Emergency Medical Form.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms