Authorization for Emergency Transportation and Treatment


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NW Synod of Wisconsin Resource Center (715) 833-1153

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AUTHORIZATION FOR EMERGENCY TRANSPORTATION AND TREATMENT

Northwest Synod of Wisconsin - Evangelical Lutheran Church in America
Lutheran Youth Organization

YOUTH INFORMATION:

Name:______________________________________________________________________________________

last first initial age date of birth

Home Address:_______________________________________________________________________________

number & street city state sex phone number

 

PARENT/GUARDIAN INFORMATION:

Name:______________________________________________________________________________________

last first initial age date of birth

Home Address:_______________________________________________________________________________

number & street city state sex phone number

 

I do [ ] do not [ ] authorize physician and hospital staff to transportt my son/daughter to a physician's office and/or emergency room in the event that emergency medical care is needed.

I do [ ] do not [ ] authorize physician and hospital staff to treat my son/daughter as they deem necessary in the emergency situation.

Name of medical insurance company:______________________________________________________________

Policy number of medical insurance: ______________________________________________________________

Is your son/daughter presently taking any medication YES [ ] NO [ ]
If yes, list medication:__________________________________________________________________________

Signature of parent/guardiarn:_______________________________________________ Date:________________

Note: This authorization will assure that your son/daughter receives medical treatment in timely manner if he/she has a broken bone or other non-life threatening illness or injury AND you are not able to be contacted to authorize medical treatment for your child.


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