Emergency Medical Care Authorization & Release from Liability for Accidents

JRC Adult Day Center Emergency Medical Care Authorization & Release from Liability for Accidents
While visiting and/or participating in the Adult Day Center, I hereby authorize the following procedures in case of medical emergency and take full responsibility for any expenses incurred.
Arrange for emergency transportation:
I prefer to be transported to:
Hospital
Phone
Contact family or person responsible for member:
1st Contact
Name
Phone
Relationship
Address
Number Street City State Zip
2nd Contact
Name
Phone
Relationship
Address
Number Street City State Zip
Contact personal/attending physician
*If personal/attending physician is unavailable, I authorize treatment by any licensed physican.
Name
Phone
Address
Number Street City State Zip
Fax
Please list all medications that are currently taken. Please indicate whether this medication is taken while attending Adult Day Services. Does the medication need refrigerated?
Please list any known allergies, whether it is to medication, foods, etc.
Are you on a special diet (i.e. Low sugar, no sodium, etc.)? If so, please be as specific as possible.
I understand that JRC Adult Day Center will make a reasonable effort to contact my physician and/or family member.
Should be Empty:

JRC Adult Day Center Emergency Medical Care Authorization & Release from Liability for Accidents