Adult Emergency Form – Fill Out and Use This PDF

Under Section 1, Basic Contact Information, enter 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 and Telephone 3.

Under In case of emergency, contact, list contact 1 and contact 2, each with Name, Relationship, Street Address, City, State, Zip Code, Telephone 1, Telephone 2 and Telephone 3.

Under Adult's Physician, enter Name and Phone.

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

Under Section 2, Insurance Information, enter Insurance Carrier, Group or Policy #, Address for Claims, Policy Holder's Name, Relationship, Policy Holder's Date of Birth and Policy Holder's Insurance ID #.

Under Health Information, for Are you allergic to anything? mark No, or mark Yes and list all allergies.

For Are you taking any medication? mark No, or mark Yes and list all medications.

For Do you have any medical/mobility/mental health concerns? mark No, or mark Yes and list them.

The information provided on this form is accurate to the best of your knowledge, and you have indicated any special health conditions that should be known to program staff and medical personnel.

If you are unable to give consent in the event of an emergency, you hereby give permission to medical personnel to administer emergency medical treatment.

Sign on the Signature line, then fill in Print Name and Date.

Acknowledge that you have read, fully understand and are voluntarily signing this release without any inducement from any member of the staff, then fill in Signature of Adult Participant and Date.