MEDICAL/EMERGENCY CONTACT

MEDICAL/EMERGENCY CONTACT
In case of a match emergency, call 858.746.9169

This card authorizes my child's Big to secure proper medical treatment or surgical procedure for my child by a qualified staff physician at a recognized hospital in the case of an emergency, illness or accident when I am not immediately available to respond.
Big's Name

First NameLast Name
Child's Name

First NameLast Name
Parent/ Guardian Signature

Clear
Parent Name (print)
Date

MonthDayYear
Date
1. EMERGENCY CONTACT NAME
1. EMERGENCY CONTACT PHONE
2. EMERGENCY CONTACT NAME
2. EMERGENCY CONTACT PHONE
3. EMERGENCY CONTACT NAME (Optional)
3. EMERGENCY CONTACT PHONE (Optional)
Child's allergies to medication and/or medical conditions
Child's Medications taken on a regular basis
Medical Insurance
Policy Number
Doctor's Name
Doctor's Phone Number
This will be reviewed by your Match Support Specialist. Please enter Match Support Specialist's name below.
Match Support Specialist Name
Match Support Specialist Phone
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