SAAC Medical Release Form

San Antonio Alumnae Chapter Delta Sigma Theta Sorority, Inc. Medical Release Form
Name

First NameLast Name
I, First Name Last Name authorize the San Antonio Alumnae Chapter (SAAC) President, First Vice President, and/or a designated Emergency Response Team (ERT) Committee Member permission to contact emergency medical services (911) on my behalf should I require medical treatment during any in-person or virtual chapter meetings, programs, or SAAC-sponsored events. I also authorize the release of all medical history or personal health information provided below to emergency medical personnel and/or first responders; I understand this information will be utilized solely for the purpose of facilitating life-saving treatment.

OR

I, First Name Last Name , authorize the San Antonio Alumnae Chapter (SAAC) President, First Vice President, and/or a designated member of the Emergency Response Team (ERT) to contact emergency medical services (911) on my behalf should I require medical treatment during any in-person or virtual chapter meetings, programs, or SAAC-sponsored events. However, I DO NOT authorize the release of any medical history or personal health information to emergency medical personnel and/or first responders. In the event of a medical emergency, SAAC will notify my designated family member and/or neighbor listed in the emergency contact information provided below.
I acknowledge and understand that by declining to provide medical history or related information, I hereby release the San Antonio Alumnae Chapter (SAAC), its officers, members, and representatives from any liabilities, responsibilities, or claims arising from the inability of First Responders to access such information.
Medical History

Please list any relevant medical conditions, allergies, medications, or other information that may assist First Responders
Medical Condition (Click Plus Sign to Additional):
Medications (Click Plus Sign to Additional):
Allergies(Click Plus Sign to Additional):
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:   First Name   Last Name

Relationship

Phone Number:   Area Code   Phone Number

Address:   Street Address   Address Line 2   City   State   Zip
Emergency Contact:   First Name   Last Name

Relationship

Phone Number:   Area Code   Phone Number

Address:   Street Address   Address Line 2   City   State   Zip
San Antonio Alumnae Chapter Medical Release Form 3
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
First Name   Last Name

Relationship

Phone Number:   Area Code   Phone Number

Address:   Street Address   Address Line 2   City   State   Zip
Acknowledgment

I acknowledge and understand that:

1. By declining the release of my medical history or related information to emergency medical services (911), I hereby release and hold harmless the San Antonio Alumnae Chapter (SAAC), its officers, members, and representatives from any liability arising from my voluntary decision to withhold the requested information.

2. This document will be kept on the SAAC website and will ONLY be accessible and VIEWED by the Chapter President, ERT Coordinator and Co-Coordinator.

3. In the event that 911 is contacted, SAAC will make reasonable efforts to notify my family member and/or neighbor identified in my emergency contact information.

4. The information provided will be used exclusively for emergency medical response and life-saving measures.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

San Antonio Alumnae Chapter Delta Sigma Theta Sorority, Inc. Medical Release Form

Medical History

San Antonio Alumnae Chapter Medical Release Form 3