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

Company

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

Minor's 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/Authorized Pickups

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 minor. Please note, any person not listed below WILL NOT be permitted to pick up the minor without written permission from a parent/guardian.

Contact 1 Name

Contact 1 Phone

Contact 1 Relationship to Minor

Contact 1 Pickup?

Yes

Contact 2 Name

Contact 2 Phone

Contact 2 Relationship to Minor

Contact 2 Pickup?

Yes

Contact 3 Name

Contact 3 Phone

Contact 3 Relationship to Minor

Contact 3 Pickup?

Yes

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

Parent/Guardian Verification/Agreement

I verify that all the information provided is correct and complete. I realize that participation involves an inherent potential risk. I grant permission for an adult leader to authorize any emergency medical treatment that may be needed for my child if they are injured or become ill while participating. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. 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.

Parent/Guardian Name*

Parent/Guardian Signature*

YAG Emergency Contacts & Medical Form (minor)