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St. Rocco Youth Group CONFIDENTIAL

NFORMATION

MERGENCY

EDICAL

UTHORIZATION

ORM

2009-2010I

NSTRUCTIONS

Please print legibly and retain a copy for your records.

Date of Birth: _____________________ Last Name ________________________ First Name _________________________ MI ____ Address _____________________________________________________________________ City ____________________________________________________ Zip _____________ Home Phone w/area code __________________________________ Please list the names of parents and/or their designees to authorize emergency medicaltreatment forchildren who become ill or injured while under Group authority. Kindly inform the Pastoror Youth Group Leader of any changes in regards to this document. In each of the #____ blanks indicate the order in which you wishcalls to be made (#1, #2, etc).R

ESIDENTIAL

ARENT OR

UARDIAN

: (Please include area codes with all numbers.)

Mother’s Name __________________________________________________ (First & Last)Day Phone ________________________ # _____ Cell Phone ________________________ # _____ Father’s Name __________________________________________________ (First & Last)Day Phone ________________________ # _____ Cell Phone ________________________ # _____

Step-Mother’s Name __________________________________________________ (First & Last)Day Phone ________________________ # _____ Cell Phone ________________________ # _____ Step-Father’s Name __________________________________________________ (First & Last)Day Phone ________________________ # _____ Cell Phone ________________________ # _____ Legal Guardian’s Name __________________________________________________ (First & Last)Day Phone ________________________ # _____ Cell Phone ________________________ # _____ I

ARENT

UARDIAN CANNOT BE REACHED

LIST DESIGNEES

(

AUTHORIZED PERSONS

): ____________________________________________________________ Relationship _______________________________ Address ___________________________________________________ ____________________________________________________ Zip _____________ Cell Phone ________________________ # _____ Day Phone ________________________ # _____ Cell Phone__________________________#_______

PARTI: TO GRANT CONSENT

(please print)

I hereby give consent for the following medical care providers and local hospital to becalled.P

HYSICIAN

___________________________________________ Phone ______________________________

(w/area code)

ENTIST

_____________________________________________ Phone ______________________________

(w/area code)

EDICAL

PECIALIST

__________________________________ Phone ______________________________

(w/area code)

OCAL

OSPITAL

_____________________________________ Phone ______________________________

(w/area code)

In the event reasonable attempts to contact me have been unsuccessful, I hereby give myconsent for:(1) the administration of any treatment deemed necessary by above-named doctors, or, inthe event thedesignated preferred practitioner is not available, by another licensed physician or dentist;and(2) the transfer of the child to any hospital reasonably accessible.This authorization does not cover major surgery unless the medical opinions of two otherlicensedphysicians or dentists, concurring in the necessity for such surgery, are obtained prior totheperformance of such surgery.Listed below are facts concerning the child’s medical history, including allergies,medications beingtaken, and any physical impairment to which a physician should be alerted: _____________________________________________________________________________ _ Date __________ Signature of Parent/Guardian_________________________________________ Address ___________________________________________________________ City _________________________________________________ Zip __________