Authorization of Emergency Medical Treatment Form

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone*
Diagnosis
Drug Allergies
Other Allergies
Physician*
Preferred Facility*
IEP
Emergency Contact*
First Last
Relationship
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 (Parent or Guardian name if under 18)*
First Last
Date
Date Format: MM slash DD slash YYYY