Emergency Medical Authorization Form
Participant Information
Full Name
Date of Birth
Gender
Address
Parent/Guardian Name (if under 18)
Contact Phone 1
Contact Phone 2
Medical Information
Primary Physician Name
Physician Phone
Insurance Company
Policy Number
List known allergies
List current medications
List known medical conditions
Emergency Contact
Contact Name
Relationship
Contact Phone
Authorization & Consent
I hereby give permission for emergency medical treatment to be administered to the participant named above if necessary. I understand every effort will be made to contact me, but if I cannot be reached, I authorize appropriate medical care.
Signature
Date