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Emergency Medical Forms

Emergency Medical Authorization Form - All Programs

"*" indicates required fields

Which program are you submitting for?*
Parent / Guardian Name*
Address*
Child's Name*
Child's Birthday*
Child's Doctor*
Child's Dentist Name*
Enter "NONE" if not applicable.
Enter "NONE" if not applicable.
Enter "NONE" if not applicable.

Emergency Contacts

Consent

Grant Consent OR Refusal to Consent*
Please read closely before you choose.
By typing your name you are signing authorization form.

Photo Release and Authorization

This RELEASE AND AUTHORIZATION acknowledges that all photographic negatives, positives, and prints shall constitute the property of St. Ambrose and may be used by St. Ambrose for any purpose determined at its discretion without further notice or any compensation to me or my daughter/son.
Photo Release and Authorization*
I (we) the parent(s) and/or guardian(s) of my minor child(ren) do hereby consent and authorize the release, publication, dissemination, distribution, use and/or reproduction of any and all photographs taken of my (our) daughter/son during her/his participation at St. Ambrose programs by an employee, agent or representative of St. Ambrose or independent contractor.
By typing your name you are signing authorization form.

Emergency Medical Form (Staff) (1)

Personal Information

Name
Address
MM slash DD slash YYYY
Do you have a Living Will?

Physician Information

Emergency Contact

Name
Disclaimer(Required)

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