Adult Emergency Form PDF Details

If you are an adult and find yourself in need of emergency medical attention, it is important to have a form filled out ahead of time that can help first responders provide the best possible care. This form can include important information such as allergies, current medications, and any other relevant health information. Having this information readily available can help ensure that you receive the appropriate treatment in an emergency situation. To download a copy of the adult emergency form, please visit our website. Thank you for your interest!

QuestionAnswer
Form NameAdult Emergency Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesblank emergency form, in case of enmergency form for adults, blank medical emergency info form, adult medical emergency form

Form Preview Example

ADULT EMERGENCY CONTACT AND MEDICAL FORM

The information requested on this page is confidential and for emergency use only. In the event of an emergency, this information will be used by program staff and emergency personnel. Please be honest when completing this form.

SECTION 1. BASIC CONTACT INFORMATION

Adult’s Last Name

 

Adult’s First Name

Adult’s Middle Name

Home Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

Zip Code

 

Date of Birth

Telephone 1:

 

Telephone 2:

 

Telephone 3:

 

 

IN CASE OF EMERGENCY, CONTACT: 1.

 

Name

 

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

City

State

Zip Code

Telephone 1:

Telephone 2:

Telephone 3:

 

 

2.

 

 

 

 

 

 

 

 

Name

 

 

Relationship

 

 

 

 

 

 

 

 

 

Street Address

 

City

State

Zip Code

Telephone 1:

 

Telephone 2:

 

Telephone 3:

 

 

 

ADULT’S PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

Phone

 

 

SECTION 2. INSURANCE INFORMATION

Please attach a photocopy of the policy holder’s insurance card as proof of insurance.

Insurance Carrier:

 

 

 

Group or Policy #:

 

Address for Claims:

 

 

 

 

 

 

 

Policy Holder’s Name:

 

 

 

Relationship:

 

Policy Holder’s Date of Birth:

 

Policy Holder’s Insurance ID #:

 

SECTION 3. HEALTH INFORMATION

Are you allergic to anything?

No.

 

Yes: Please list all allergies.

Are you taking any medication?

No.

 

Yes: Please list all medications.

Do you have any medical/mobility/mental health concerns of which we should be aware?

No.

 

Yes: Please list.

The information provided on this form is accurate to the best of my knowledge, and I have indicated any special health conditions that should be known to program staff and medical personnel. If I am unable to give consent in the event of an emergency, I hereby give permission to medical personnel to administer emergency medical treatment.

Signature:

 

Print Name:

Date:

 

 

 

 

 

Participant Liability and Photo Release Form

I, ___________________, hereby release, indemnify, and hold harmless Warren Wilson College,

the Exploring Joara Foundation, Tulane University, University of Michigan, Western Piedmont Community College, and their respective officers, directors, employees, agents, contractors, subcontractors, representatives, successors and assigns, and all persons conducting directly or indirectly, the activities surrounding my involvement as a program participant from any and all claims, rights, demands, actions, causes of action, expenses and damages, which I or my heirs, personal representative, successors, assigns or anyone claiming by, through or under me ever had, now have, or may have against the parties identified above arising from any injury, act or omission relating in the way to my participation as a program participant.

I understand that I will not be entitled to and will not receive Worker’s Compensations benefits or other similar payments from Warren Wilson College, the Exploring Joara Foundation, Tulane University, University of Michigan, or Western Piedmont Community College, under the law of the State of North Carolina in the event that I am injured.

I hereby provide consent to these institutions to copyright, publish, use, sell or assign any and all photographic portraits or pictures, television spots, movie films, videotapes, and/or sound records or any part thereof, that they may take or make of me during my time as a program participant in which I may be included in whole or in part, whether separate from or in conjunction with, illustrative or written manner, story or news item, motion pictures, television or radio spots, or for publicity, advertising or any other lawful purpose whatsoever, in conjunction with my name or in anonymity. I hereby waive any right I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied. I hereby waive all claims for compensation of such use or for damages.

I acknowledge that I have read, fully understand and am voluntarily signing this release without any inducement from any member of the staff.

________________________________________________________________________

Signature of Adult Participant

Date

How to Edit Adult Emergency Form Online for Free

It is possible to work with in case of enmergency form for adults easily by using our PDFinity® online tool. The editor is consistently maintained by our staff, acquiring new functions and turning out to be greater. To begin your journey, go through these easy steps:

Step 1: First of all, access the editor by clicking the "Get Form Button" in the top section of this page.

Step 2: With this handy PDF tool, you can actually accomplish more than just complete blank fields. Try each of the features and make your docs look high-quality with custom text added in, or tweak the file's original input to perfection - all comes along with an ability to incorporate any kind of photos and sign the PDF off.

Filling out this PDF needs thoroughness. Ensure that every field is done correctly.

1. While filling out the in case of enmergency form for adults, ensure to include all of the essential blank fields in their corresponding section. It will help hasten the process, allowing for your information to be processed fast and correctly.

Filling out section 1 of adult emergency contact

2. Given that the previous section is finished, it's time to put in the essential details in Relationship, State, Zip Code, Telephone , Phone, Home Address Telephone IN CASE OF, Street Address, Name, Name, City, Telephone , SECTION INSURANCE INFORMATION, and Group or Policy in order to go to the next part.

Tips to fill out adult emergency contact step 2

3. Within this stage, examine SECTION INSURANCE INFORMATION, Relationship, and Policy Holders Insurance ID . Every one of these are required to be filled in with greatest precision.

Completing segment 3 in adult emergency contact

4. This next section requires some additional information. Ensure you complete all the necessary fields - Yes Please list all allergies, Yes Please list all medications, Are you allergic to anything No, and Yes Please list - to proceed further in your process!

Part number 4 in submitting adult emergency contact

When it comes to Yes Please list all medications and Are you allergic to anything No, make sure you get them right here. Both of these are considered the key fields in the file.

5. The pdf must be wrapped up by dealing with this area. Further there can be found a comprehensive list of fields that require correct details in order for your document usage to be complete: The information provided on this, Print Name, and Date.

Step number 5 of completing adult emergency contact

Step 3: Look through the details you've typed into the form fields and click the "Done" button. Sign up with FormsPal right now and instantly gain access to in case of enmergency form for adults, set for download. Every change made is conveniently kept , letting you customize the pdf later on as needed. We do not share or sell the details you use when completing documents at our website.

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