Adult Emergency Form PDF Details

What the Form Covers

The Adult Emergency Contact and Medical Form collects information across four key sections:

Who Needs This Form

Any adult participating in an organized program or activity benefits from having an emergency form on file. Camp coordinators, coaches, activity leaders, and care facility managers commonly require this document. It works alongside other protective paperwork, such as a Medical HIPAA Release or a general consent form, to build a complete safety record for each participant.

Legal and Medical Authorization

Many versions of this form include a clause authorizing emergency medical treatment when the participant cannot give consent. They may also include a liability waiver and a photo release. For longer-term medical planning, participants often pair this form with a Medical Power of Attorney, a Living Will, or a DNR Order to ensure medical preferences are documented in advance.

Related Emergency Forms

For a compact version to carry in a wallet or bag, consider the Emergency Card form. Families can also find dedicated student emergency information cards for school and youth programs.

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 emergency 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

You can complete this adult emergency form online using our PDFinity® editor. Follow these steps to fill it out accurately and completely.

Steps to Fill Out the Adult Emergency Form

Step 1: Click the "Get Form" button at the top of this page to open the editor.

Step 2: Add your personal details in the first section, including your full name, home address, date of birth, and contact phone numbers. Fill every field - incomplete contact information makes the form less useful in an emergency.

Filling out section 1 of adult emergency contact

Step 3: Enter your emergency contacts. Include their name, relationship to you, and at least two reliable phone numbers so coordinators can always reach someone.

Tips to fill out adult emergency contact step 2

Step 4: Complete the insurance information section with your policy holder name, carrier name, group number, and insurance ID. Attaching a copy of your insurance card is recommended where possible.

Completing segment 3 in adult emergency contact

Step 5: Fill in the health information section. List all allergies, current medications with dosages, and any pre-existing conditions. These fields are required - accurate health information allows first responders to deliver faster and safer care.

Part number 4 in submitting adult emergency contact

Step 6: Review the treatment authorization clause and any liability or photo release language, then print your name, sign, and date the form.

Step number 5 of completing adult emergency contact

Step 7: Click "Done," then download or print your completed form. Sign up for a free FormsPal account to save the file and return to update it whenever your health information changes.

Frequently Asked Questions

Who needs an adult emergency form?

Adults joining organized programs, camps, sports leagues, or care facilities typically must complete an emergency form before participating. Coordinators use it to reach designated contacts and inform medical staff of health conditions during a crisis.

What should I include in the medical history section?

List all known allergies (food, medications, and environmental), all current prescription and over-the-counter medications with dosages, and any chronic conditions such as asthma, diabetes, or heart disease. Leaving these fields blank can delay or complicate emergency treatment.

How often should I update my adult emergency form?

Review and update your form whenever your health information changes - for example, after starting a new medication or receiving a new diagnosis. Keeping emergency contact numbers current is equally important. You can return to FormsPal at any time to edit your saved copy.

What other safety documents should I keep on file?

An adult emergency form works best alongside a portable emergency card. For longer-term health planning, consider also filing a Living Will or Medical Power of Attorney to document your medical preferences in advance.

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