Breaking the Silence New Mexico » YAG Emergency Contacts & Medical Form (18+)

URL

This field is for validation purposes and should be left unchanged.

Participant Name*

Date of Birth*

Gender

Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Name*

Parent/Guardian Phone*

Parent/Guardian Email*

Emergency Contacts

Please list other possible individuals who may be contacted in case of emergency if you are not available, and whether or not they are authorized to pick up the participant.

Contact 1 Name*

Contact 1 Phone*

Contact 1 Relationship to Participant*

Contact 2 Name

Contact 2 Phone

Contact 2 Relationship to Participant

Contact 3 Name

Contact 3 Phone

Contact 3 Relationship to Participant

Medical Information

Insurance Carrier (if any)

Policy Number

Family Doctor or Facility

Phone

Special Health Conditions*

Check all that apply.

Other Health Conditions*

Medications

Medications*

I take medications for ongoing health conditions, which I will list below

I do not take medications for ongoing health conditions

Medication 1*

Med 1 Dose*

Medication 2

Med 2 Dose

Medication 3

Med 3 Dose

Allergies

Please describe reactions and severity.

Special Dietary Needs

Verification/Agreement

I verify that all the information provided is correct and complete. I realize that participation involves an inherent potential risk. I agree to be responsible for any necessary charges incurred by any hospitalization or treatment received during participation. I realize that the health information described above will be kept in confidence. However, I give my permission for it to be shared with any adult in charge of a trip/event on a need-to-know basis as determined by the Youth Program Coordinator.

Your Signature*

YAG Emergency Contacts & Medical Form (18+)