Medical Information and Emergency Release Form

Wildwood Chapel Ministries

Wildwood Chapel Ministries – 7296 T.H. 51 – Upper Sandusky, OH 43351 419-294-4610 wildwoodchapel@gmail.com
Medical Information and Emergency Release Form

In the unlikely event that a medical problem should arise we would like to have all of the relevant medical and health information on record. If this problem should be an emergency or you are for some reason unable to make decisions or sign documents for yourself, we need you to also give the Wildwood Chapel staff your permission to act in your behalf in the event of an emergency. Please carefully read and complete the following information and sign as needed.
Minor Name
Birth Date
Address
City, State & Zip
Home Phone
Gender

FemaleMale
Please list and explain any special medical information such as unusual medical conditions, allergies to medications or foods, current medications being used, unusual physical conditions, etc.
I do hereby give my permission for the personnel of Wildwood Chapel or their agents, to seek medical attention and treatment for me as needed. W.C.'s agent may act in my behalf to secure and approve any and all necessary medicine, treatment, surgery, or procedure deemed necessary by attending medical personnel. I understand that I and my personal insurance company are fully responsible and liable for any and all expenses incurred as a result of attaining and administering these services and treatments.
Please print name
Date

MonthDayYear
Date
Signature

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Emergency contact person and information
Insurance Co. Name
Policy Number
Please explain any information or instructions on how to activate your insurance policy in an emergency. Please also list any information you would like regarding special needs, additional phone numbers, family doctor's name and number, etc.
Should be Empty:

Wildwood Chapel Ministries