Emergency Medical Treatment Form - Destiny Youth Ranch

Destiny Youth Ranch

Emergency Medical Treatment Form

(Please copy & paste this form into a document & print off. You will need this form filled out for every person that will be volunteering or participating at camps or retreats.)
Authorization for Emergency Medical Treatment Form

Name:___________________________________DOB:_Phone:
Address:__________________________________________
Physician’s name:Preferred Medical Facility:
Health Insurance Company:_Policy #:_
Allergies to Medication or Food:________
Current Medications:
Date of last Tetnus shot:_

In the event of an emergency, contact:
Name:_Relationship:_Phone:
Name:_________________Relationship:_Phone:
Name:_________________Relationship:_Phone:
Name:_________________Relationship:_Phone:

In the event of an emergency: If medical aid/treatment is required due to injury during the process of receiving services, or while being on the property of “the stable”, I authorize Destiny Youth Ranch staff member to:

1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan

This authorization includes x-rays, surgery, hospitalization, medication, and treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

Date:_Consent Signature:_

Non-Consent Plan

I do not give my consent for emergency medical treatment/aid on the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:______________________________________________________________________________________________________________________________________________________________________________________________________
Date:Consent Signature:_