Emergency Medical Authorization

Whipple Heights Alliance Church

Emergency Medical Authorization

Your child's saftey is of utmost importance to us. Your authorization empowers us to care for your child in the unlikely event (s)he requires medical attention while under our care.

Before you get started, we recommend reviewing the form to see what information you need to have available. We'd hate for you to get part way through and find a required field that you can't complete. That would be really frustrating. There are five sections to this authorization:

Student Information
Guardian Information
Emergency Contact
Medical Information
Authorization for Treatment

Please Note: After submitting this form, a PDF copy will be emailed to you. You must print that PDF, physically sign it, and return it to the church office.

The good news? You only need to do this once per calendar year or whenever your information changes.

1. Student Info

Name

First Name*

Middle Name

Last Name*

Birthdate

Required* //

Gender
Required*

	Female
	Male

Primary Phone

Required* --

If student does not have a mobile phone, enter a guardian's phone.

Primary Address

Street 1*

Street 2

City*

State*

Zip*

School

Required*

Grade
Required*

During this summer, please select the grade this student will enter in the Fall.

2. Guardian Info

Legal Guardian 1

First Name*

Last Name*

I would like to receive occasional kids ministry updates from the church.

I would like to receive occasional youth ministry updates from the church.

Relationship

Required*

Primary Phone

Required* --

Secondary Phone

E-mail

Required*

Legal Guardian 2

First Name

Last Name

I would like to receive occasional kids ministry updates from the church.

I would like to receive occasional youth ministry updates from the church.

Relationship

Primary Phone

Secondary Phone

E-mail

Residency

Please explain any special custody/residency arrangements of which we should be aware.

3. Emergency Contact

In the event we are unable to reach either person listed above, who else should we attempt to contact?

Name

First Name*

Last Name*

Please name someone OTHER THAN the two guardians already listed above.

Relationship

Required*

Primary Phone

Required* --

Secondary Phone

4. Medical Info

Insurance Provider

Required*

If you do not carry medical insurance, please indicate "none."

Group or Plan ID

Required*

Insurance Policy Holder

First Name*

Middle Name

Last Name*

Policy Holder's Date of Birth

Required* //

Physician

Required*

Phone

Required* -- ext

Dentist

Required*

Phone

Required* -- ext

Health Conditions

Please select all conditions that may require attention while participating in a church event (on or off campus).

Please provide explanations for all items marked above.

Medications

Required*

List all medications and dosages this child receives on a regular basis. If none, enter "none."

5. Authorization

Select One
Required*

	In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the designated physician or dentist, or in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to the designated hospital or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
	I do not give my consent for the emergency medical treatment of my child. In the event of illness or injury requiring medical treatment, I wish the Whipple Heights Alliance Church staff and volunteers to take no action.
	I do not give my consent for the emergency medical treatment of my child. In the event of illness or injury requiring medical treatment, I wish the Whipple Heights Alliance Church staff and volunteers to follow the instructions provided below. (If no instructions are provided, I wish no action to be taken.)

Instructions

Media
Required*

I give consent for photographs and/or videos of my child to be taken and used in public communication including, but not limited to, websites, social media, print materials, etc.

Name of Person Granting Authorization

First Name*

Last Name*

E-mail

Required*

A PDF copy of this form will be sent to this address for your physical signature.

Signature

Leave this field blank. You must physically sign the PDF we'll email you in a few minutes.