Emergency Contact Form

Emergency Contact and Medical Information for a Child

Alternative Emergency Contacts

Medical Information

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

I give permission for my child to go on field trips. I release [Organization] and individuals from liability in case of accident during activities related to [Organization], as long as normal safety procedures have been taken.


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