EMERGENCY CONTACT FORM

EMERGENCY CONTACT FORM

As much as we trust and believe that God will cover and protect us throughout this program, we also want to be wise, safe, and fully prepared. In the event of an unexpected situation, having accurate emergency contact information helps us respond quickly and responsibly.

Please take a moment to fill out this form carefully and to the best of your ability. Your cooperation ensures the well-being and safety of everyone in attendance.
Authorization for Emergency Medical Treatment
Name of event
What is the name of the HAVEN event that you are attending?
I. MEDICAL INFORMATION

Attendee Information
a. Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number*
b. Name of Nearest Relative*

First NameLast Name
Address of Nearest Relative*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number of Nearest Relative*
c. Physician's Name*
Physician's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physician's Telephone Number*
e.Insurance Company Name*
Policy Number*
Insurance Telephone Number*
f. Allergies*
g. Current Medications*
h. Special Health Needs*
II. EMERGENCY MEDICAL AUTHORIZATION
I, the undersigned, do hereby authorize The HAVEN Missions and its agents or representatives to consent, on my behalf,
to any medical/hospital care or treatment (including locations outside the U.S.) to be rendered upon the advice of any licensed
physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this
authorization.
The effective dates of this authorization are*

MonthDayYear
I am eighteen years of age or older, have read the above authorization, and confirm that the information contained therein is true and
accurate.
(Signature of Individual Providing Authorization)*

Clear
Date*

MonthDayYear
Should be Empty:

Authorization for Emergency Medical Treatment

I. MEDICAL INFORMATION

II. EMERGENCY MEDICAL AUTHORIZATION