Emergency
Medical Information for Minor Child
1. Minor's name____________________________________________
2. Father's name___________________________________________
Address________________________________Telephone_________________
3. Mother's name___________________________________________
Address________________________________Telephone_________________
4. Physician's name_________________________________________
Address________________________________Telephone_________________
5. Insurance company________________________________________
Policy no._______________________________Group no.__________________
Name of insured__________________________Telephone_________________
6. Does Youth Member have any allergies?____________________________________
7. Does Youth Member have restrictions
on activities? ____________
If yes, describe____________________________________________________
8. Does Youth Member have any other
medical conditions of which we should be aware? ___
If yes, describe____________________________________________________
9. Does Youth Member take any medications
of which we should be aware?___________
______________________________________________
10. Blood type_________________________
Sponsor Agreement and Emergency Medical Care Release
I, _________________________,
parent/guardian of _____________________ give permission to SAI Region 1 events coordinators to sponsor my child and make
decisions in the case of a medical emergency while she is participating in the Young Women in Harmony workshop to be held
at the Sheraton Ferncroft, in Danvers, MA, on Saturday, January 24, 2009.
In the event of a medical emergency, I give my permission to the
physician selected by the sponsor to provide all necessary and appropriate medical care to the minor child including but not
limited to hospitalization, injections, anesthesia, and surgical procedures.
_____________________________________________________________
Date
Parent/guardian signature
