EMERGENCY MEDICAL AUTHORIZATION FORM

Courtesy medids.com and AUMC (PGPC has altered to fit the need of our events)

I, ____________________________________________________________________________

Parent/Guardian of _______________________________________ Born on ________________

do hereby give my consent to PLEASANT GROVE PRESBYTERIAN CHURCH to secure and authorize such emergency medical treatment as the above name requires while under the supervision of said care provider. I also agree to pay all the costs and fees contingent on emergency medical care or treatment for this person as secured or authorized under this consent.

NOTE: Every effort will be made to notify the parents/guardian, etc. in case of emergency. In the event of an emergency, it would be necessary to have the following information (see back for allergies, etc.):

Parent cell phone number: ______________     Home number: ___________________

Physician’s Name: __________________________    Phone number:________________________

Preferred Hospital: ______________________________________________________________

Address: ______________________________________________________________________

Insurance Company: ____________________________ Policy #: _________________________

Name of Insured: ________________________________

If the parents/guardian is unavailable, other relatives or persons to contact in emergency:

Name: ________________________________________

Address: ______________________________________

Phone: _______________________________________

Relationship: ___________________________________

Signature: ________________________________________________

Date: ________________

The safety of your children is of our utmost concern. Thank you again for sharing your children with us.

ADDITIONAL INFORMATION

Please list for us any allergies that we need to be aware of.  Please know that if allergies are severe enough to require the need of a life saving EpiPen, you may be asked to volunteer so that you are onsite in case of a true emergency.

Are there any other conditions that we should be aware of?                   YES                 NO

If yes, please explain:

Thank you in advance for helping us to keep your children safe during this event.