Emergency Medical Consent

Emergency Medical Consent

For activities related to Hope Community Church, Wymondham. This is not the event booking form - please make sure you complete that separately. Information submitted here will be confidential and not passed on to third parties.
Name of Event
Date of Event
Name of Child

First NameLast Name
Birth Date*

DayMonthYear
Address*

House Name/Number

Street Address

CityCounty

Post CodeCountry
Contact Home Number*

Area CodePhone Number
Contact Mobile Number
Allergies or Medical Conditions (e.g. medicine, food, insects, asthma, fits, migraines, epilepsy, disabilities etc) we should be aware of:
Allergies/Medical Conditions
Doctor
Name of Doctor
Surgery Address
Location Address of your Doctor's Surgery
Surgery Telephone Number
Emergency Medical Consent*

In the event of illness or accident requiring emergency treatment, I authorise the team leader or organisation staff to sign on my behalf any written form of consent required by the doctor/hospital/dental authorities if the delay required to obtain my own signature is considered inadvisable by the medical staff concerned.
Print Name of Parent/Gaurdian:*
Signature of Parent/Guardian (Use your mouse or finger to draw)*

Clear
e signature

Clear
smooth Signature
Form Created by Adam Jackson - hello@tomorrownight.com
Should be Empty: