THOMPSON PARK DOLPHIN SWIM TEAM
EMERGENCY MEDICAL FORM
PLEASE FILL OUT ONE FORM FOR EACH SWIMMER IN YOUR FAMILY
Current Medications: ____________________________________________________________________
Anything to which a physician should be alerted: _____________________________________________
CONTACTS
First: _______________________________ Phone:____________________________
Fourth: _____________________________ Phone: ____________________________
Part I or Part II MUST be completed
Part I – To GRANT Consent
In the event that reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist, and (2) the transfer of the child to any hospital reasonable 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 prior to the performance of such surgery.
Parent/Guardian Signature: ______________________________________ Date: _____________________
Part II – To REFUSE to Consent
I do not give my consent for emergency treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the
authorities to take the following action:
____________________________________________________________________________________________
Parent/Guardian Signature: ______________________________________ Date: __________________________