Emergency Medical Authorization 2023 - Adult Step 1 of 3 33% Contact InformationName(Required) First Last Birth Date(Required) Month Day Year Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Emergency Contact InformationPrimary Contact First Name(Required) Primary Contact Phone Number(Required) Medical InformationPlease list any information concerning child's medical history below. (Include allergies, medications, etc.)Medical Insurance Company(Required) Member ID#(Required) Group #(Required) Consent to Administer Treatment(Required)In the event reasonable attempts to contact us at provided numbers have been deemed unsuccessful, I/we hereby: Grant Consent to Administer Treatment DO NOT Grant Consent to Administer Treatment Consent to Administer TreamentTreatment may be administered by the following preferred providers:Preferred Physician Preferred Physician Contact Phone Preferred Dentist Preferred Dentist Contact Phone Preferred Hospital (if necessary) DO NOT Consent to Administer TreatmentIn the event of injury or illness requiring emergency medical treatment, leaders are to provide reasonable first aid care and will continue to try to contact me/us using the information provided. Any further instructions are listed below:Further care instructions, if any Electronic Signature Confirmation(Required)By providing an electronic signature below, I agree that all the information provided in this form is true and complete to the best of my knowledge. This form is considered current for one year from the date of submission. If there are any changes or further information is needed regarding my care, I will contact the leaders of St. Peter Church, as soon as possible. I agreeElectronic Signature - First and Last Name(Required) Do not say, “I am too young.” To whomever I send you, you shall go; whatever I command you, you shall speak. Jeremiah 1:7
