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Adult Annual Emergency Medical Care Form

Adults MUST complete this form prior to the commencement of each Parish Youth Ministry Program year. Adults are responsible for updating the information on this form (by submitting a new form) should changes occure during the year.

Consent to Emergency Medical Care
In the event of an emergency, I request that the parish make reasonable attempts to contact the names and numbers I will list on this form. I understand that in an emergency, exigent circumstances may prevent the parish from contacting my listed emergency contacts immediately, or the parish may be unable to reach them. I therefore consent to the parish taking action which it deems necessary to secure emergency medical care/treatment. I understand that decisions concerning the type of emergency medical care or treatment administered are normally made by health care provider and not by the parish and that exigent circumstances may require the administration of emergency medical care or treatment without my prior consent. However, I have indicated, on this form, any treatment preferences I have which the parish may disclose to a health care provider.
Name
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Parish
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E-mail
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Emergency Contact Name(s) and Phone Number(s)
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My preferred physician (with phone number) is:
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My preferred dentist (with phone number) is:
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My preferred hospital is:
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Other Medical Preferences
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Insurance Company Name
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 By completing this section, I give permission for the following insurance information to be disclosed to a health care provider.
Insurance Policy/Group/Claim/#'s
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 By completing this section, I give permission for the following insurance information to be disclosed to a health care provider.
Allergies/Medical Information
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 By completing this section, I give permission for information pertaining to allergies, medications, etc to be disclosed to a health care provider.
Digital Signature
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 By typing my full name and today's date, I agree to the following: I understand that in the event of any emergency, the parish will make reasonable efforts to notify a health care provider of my choice, as indicated on this form, but I acknowledge that I am responsible for communicating such information to the appropriate medical personnel.
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