Authorization for Emergency Transportation and Treatment

From the Open Files of: NW Synod of Wisconsin Resource Center (715) 833-1153 Contributed by: This file is available in Rich Text Format version for editing

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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