Emergency Contact and Medical Information Form

This is a Emergency Contact and Medical form just in case anything happens, we have on file what to give to medical Professionals Only. Your information will not be shared with no other parties and will be kept confidential.

Name: Fill name Here

Date of Birth: date

Address: address

City, State, Zip: address 2

Home Phone: h number

Cell Phone: c num

Email: email

Alternative Emergency Contacts

Primary Emergency Contact

Name: name

Home Phone: phone

Cell Phone: cell

Work Phone: work

Secondary Emergency Contact

Name: name

Home Phone: phone

Cell Phone: cell

Work Phone: Work

Medical Information

Hospital/Clinic Preference: Hospital name

Physician’s Name: Name

Phone Number: number

Insurance Company: Insurance

Policy Number: Number

Allergies/Special Health Considerations: allergy's

Health Conditions?

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for myself and waive my right to informed consent of treatment. This waiver applies only in the event that neither emergency contacts can be reached in the case of an emergency.

Signature: Sign

Date: date

I release Team Yayo and individuals from liability in case of accident during activities related to Team Yayo , as long as normal safety procedures have been taken.

Signature: Sign

Date: Date

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This is version 1, from 3 years ago.

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