WESTERVILLE ROWING CLUB, INC.

EMERGENCY INFORMATION 1 AUTHORIZATION FORM

Please Print

Student's Name Grade

Last First

Street Address School
City Zip Home Phone Birthdate

Name of Legal Guardian Address

With whom does the child reside? (Parents, legal guardian, Mother, Father, joint custody, etc.)

Mother's Name Home Phone

Last First

Mother's Place of Employment Work Phone

Father's Name Home Phone

Last First

Father's Place of Employment Work Phone

List two neighbors or nearby relatives who will assume temporary care of your child if you cannot be reached:

1. Name Address Telephone

2. Name Address Telephone

EMERGENCY MEDICAL AUTHORIZATION

PART I OR PART 2 MUST BE COMPLETED

PART I (TO GRANT CONSENT)

In the event reasonable attempts to contact me at or

Phone Other Parent

at have been unsuccessful, I hereby give my consent for (I) the administration of any treatment

Phone

deemed necessary b y Dr. at or

Preferred Physician Phone

Dr. at or in the event the designated preferred

Preferred Dentist Phone

practitioner is not available, by another licensed physician or dentist; and (2) the transfer of my child

to or any hospital reasonably accessible. This

Preferred Hospital

authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in necessity for such surgery. are obtained before surgery is performed. Please list facts concerning your child's medical history to which a physician should be alerted:

Allergies: Medications:

Health Concerns (Diabetes, Asthma, etc..):

Physical Impairments: Date of Last Tetanus Booster:

Signature of Legal Guardian Date

Part 2 (REFUSAL OF CONSENT) DO NOT COMPLETE PART 2 IS YOU COMPLETED PART I

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment,

I wish the school I club authorities to TAKE NO ACTION OR TO:

Signature of Legal Guardian: Date: