Adult Medical & Emergency Contact Form

Adult Medical & Emergency Contact Form

Georgia FCCLA 2026-2027
Adviser / Chaperone Information
Chapter/School Name
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information

In the event of a medical emergency, please provide us with the following information
Do you have any medical conditions we should be aware of?
If "Yes", please list/describe the medical conditions
Do you have any allergies (including medications, foods, and the environment)?
If "Yes", please list allergies.
Do you have any dietary restrictions?
If "Yes", please list dietary restrictions
Are you currently taking any medications?
If "Yes", please list current medications.
Physician's Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Information

In the event of an emergency, please provide us with the person we should contact on your behalf.
Emergency Contact Full Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Consent Agreement

In the event of a medical emergency, I authorize Georgia FCCLA staff and event medical personnel to seek emergency medical treatment on my behalf if I am unable to provide consent. I understand that I am responsible for any costs incurred in such treatment. By signing below, I agree to the above statement.
Signature
Should be Empty:

Adviser / Chaperone Information