Authorization of Emergency Medical Treatment Form Name of Participant * First Name Last Name Date of Birth * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Please describe any diagnosis that Hope's Haven should be aware of. Please list any allergies Include any drug allergies Physician * Preferred Facility * IEP Emergency Contact * First Name Last Name Relationship Option 1 Option 2 Emergency Contact Phone * (###) ### #### Consent Signature If emergency medical aid/treatment is requited due to illness or injury while at the facilities used by Hope's Haven Rescue/Youth Camp, at an event sponsored by HHRYC, or at an event in which HHRYC is a participant. I authorize Hope’s Haven Rescue and Youth Camp to secure and retain medical treatment and transportation if needed. This authorization includes x-ray, surgery, hospitalization, medication, and treatment deemed “life-saving” by the physician if the person listed as Emergency Contact cannot be reached. I understand and agree to the Authorization of Emergency Medical Treatment. Name of Parent or Guardian * First Name Last Name Date * MM DD YYYY Thank you!
