Member Intake Form

MEDIA RELEASE
Date

MonthDayYear
Member Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
I First Name Last Name, hereby give permission for CFLT to photograph or videotape me which can be used for advertising, media events and/or any other lawful purpose. I understand that this release will be valid for 1 year from the date of signature.
Signature of Member

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Signature of Guardian

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Name

First NameLast Name
Email
example@example.com

EMERGENCY TREATMENT AGREEMENT
Date

MonthDayYear
Member Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
I give consent to the Center for Life Transitions to administer acetaminophen up to 650 mg, in the event of headache, pain, or fever. You will be notified in the mode established by you of the time and the amount given.

In the event of an emergency, including illness, accident or injury, I hereby give permission for CFLT to call:
1. Name:   First Name   Last Name Phone #
2. Name:   First Name   Last Name Phone #

In the case of serious illness or injury requiring transportation to a hospital, I would like to be transported to the following hospital:
Type a label
Type a label
Type a label
Signature of member

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Signature of Guardian

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Name

First NameLast Name
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Appointment
This is a fill in the blanks field. Please add appropriate blank fields and text.
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AUTHORIZATION FOR DISCLOSURE OF PERSONAL AND HEALTH INFORMATION
Purpose

For the authorization to disclose personal information, which may include health information, to persons or organizations outside of an individual’s support team. An individual’s privacy is protected by state and federal privacy laws. As such, CFLT needs your explicit permission to make the requested disclosure. Please complete each section of this form.

Your name and identification information:
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Last 4 of your social security Number*
To whom are we authorized to disclose your personal information?

Please state the names of the individuals or organizations, including contact information:
Name:   First Name   Last Name Phone #
Name:   First Name   Last NamePhone #
Name:   First Name   Last NamePhone #
Signature

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Guardian's Signature (If applicable)

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Date

MonthDayYear
For questions about this authorization or to revoke this authorization, please contact:

Center for Life Transitions, 2324 Lake Ave, Ft. Wayne, IN 46805 260-201-1900
Should be Empty:

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