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
