SHOWCASE AMERICA UNLIMITED
EMERGENCY MEDICAL FORM
Name: _______________________________________ Age & Birth Date: ___________________
Parent or Guardian: _________________________________ Social Security: ________________
Address: _______________________________________________________________________
Street Address City State Zip
Home Phone: ________________________ Daytime or Cell Phone: _______________________
Director/Chaperon Attending Group: __________________ Team Name: ___________________
MEDICAL INFORMATION
Family Physician: ________________________________ Physician Phone: ________________
Family Insurance Company: ___________________________ Group/Policy #: ______________
Is participant allergic and/or hypersensitive to any medication and/or medical treatment:
_____ Yes _____ No If Yes, Please List: _________________________________________
Last Tetanus Toxiod (if known): ____________________________________________________
Facts concerning the participant’s medical history including allergies, medications being taken,
any physical impairment to which a physician should be alerted: ______________________
__________________________________________________________________________
Dentist Name: _______________________________ Dentist Phone: __________________
CONTACT IN CASE OF EMERGENCY
#1 NAME: _______________________________ #2 NAME: ___________________________
Relationship: ____________________________ Relationship: __________________________
Home Phone: ____________________________ Home Phone: ___________________________
Work Phone: ____________________________ Work Phone: ___________________________
PLEASE READ AND SIGN BELOW
State Law requires a parent or guardian’s consent for medical treatment and procedures as deemed necessary in case of an emergency for a minor. Please also secure a notary to document your signatures, as some treatment centers will only recognize an authorization form of this sort that has been notarized.
I hereby authorize SHOWCASE AMERICA and its authorized representative or emergency medical personnel to furnish emergency services and/or secure treatment (transport to a hospital and hospital admission) for my child or myself. I agree to be financially or otherwise responsible for this service.
I release, discharge and agree to hold harmless Showcase America Unlimited, their officers, employees, agents and all others who could be held liable from any and all claims, which in any manner arise from or as a direct or indirect result of this service.
SIGNATURE OF PARENT /GUARDIAN OF STUDENT:_____________________________________
DATE:_______________________________
