Emergency Medical Authorization Form - Youth Ministry

"*" indicates required fields

Parent / Guardian Name*

First Last

Parent/Guardian Email*

Parent / Guardian Phone*

Address*

Street Address City State ZIP Code

Child's Name*

First Last

Child's Birthday*

Child's Doctor*

First Last

Child's Doctor Phone:*

Child's Dentist Name*

First Last

Child's Dentist Phone*

Hospital of Choice*

Hospital Phone*

Insurance Provider*

Insurance Provider Phone*

Medical issues/concerns:*

Enter "NONE" if not applicable.

Allergies or sensitivities to any food, drink, or materials that might be used during class:*

Enter "NONE" if not applicable.

Activities in which your child(ren) may not participate?*

Enter "NONE" if not applicable.

Emergency Contacts

Name of Emergency Contact 1*

Relationship to Child

Best Phone to Reach Emergency Contact 1*

Name of Emergency Contact 2*

Relationship to Child

Best Phone to Reach Emergency Contact 2*

Consent

Grant Consent OR Refusal to Consent*

Please read closely before you choose.

GRANT CONSENT: In the event reasonable attempts to contact me at the above numbers have been unsuccessful, I hereby grant my consent for (1) the administration of any treatment deemed necessary by the above medical professionals, or in the event the designated preferred practitioner or facility is not available, by another licensed medical practitioner; and (2) the transfer of the child to the above named facility or any reasonably accessible hospital. The authorization does not cover any major surgery unless the medical opinions of two (2) other licensed physicians or dentists concur in the necessity for such surgery and concurrence is obtained before the surgery is performed.

REFUSAL TO CONSENT: I do not give my consent for emergency medical treatment of my child. In the event of illness or emergency treatment being required, I wish the school authorities to take no action

Please type your NAME and DATE*

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*

YES

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.

Please type your NAME and DATE*

By typing your name you are signing authorization form.

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