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:_______________________________