RockHouse Emergency Medical Authorization

2024-2025 ECC Student Emergency Medical Authorization

Purpose: To enable parents to authorize emergency treatment for their child who may become ill or injured while under ECC supervision.
Participant's Name*

First NameLast Name
Birthdate*

MonthDayYear
Are you an adult on this trip?

YesNo
Parent's Name(s)

FatherMotherPhone
Guardian's Name

First NameLast NamePhone
Person to contact if parent/guardian cannot be reached:
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Medical Information and History:
Allergies (medical, food, other):
Physical Impairments:
Existing Conditions:
Other:
Dental Appliance:*

YesNo
Contact Lenses:*

YesNo
TRAVEL PERMISSION: If transportation is provided, I give permission for my child to be transported by ECC Student Ministries*

YesNo
To Grant Consent - Form Must Be Completed, Signed & Dated

By Parent or Guardian
This form, when signed, is in effect for all activities that occur from June 1, 2024 through June 1, 2025
In the event reasonable attempts to contact me at the number listed above have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by a licensed physician or dentist and the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring, in the necessity for such surgery, are obtained BEFORE THE SURGERY IS PERFORMED.

Further, as parent or legal guardian, I am responsible for the health care decisions for my minor child and agree that my insurance plan is the primary plan to pay for the dental, medical or hospital care or treatment that is given to my child. Any policy of the church or organization sponsoring this event will be used as the secondary coverage.
Parent/Guardian Signature*

Clear
Should be Empty:

2024-2025 ECC Student Emergency Medical Authorization