Emergency Medical Authorization

Whipple Heights Alliance Church

Emergency Medical Authorization

Your child's saftey is of utmost importance to us. Your authorization empowers us to care for your child in the unlikely event (s)he requires medical attention while under our care.

Before you get started, we recommend reviewing the form to see what information you need to have available. We'd hate for you to get part way through and find a required field that you can't complete. That would be really frustrating. There are five sections to this authorization:

  1. Student Information
  2. Guardian Information
  3. Emergency Contact
  4. Medical Information
  5. Authorization for Treatment

Please Note: After submitting this form, a PDF copy will be emailed to you. You must print that PDF, physically sign it, and return it to the church office.

The good news? You only need to do this once per calendar year or whenever your information changes.

1. Student Info
Name
  •  
Birthdate //
  •  
Gender
  •  
Primary Phone --
  •  
If student does not have a mobile phone, enter a guardian's phone.
Primary Address
  •  
School
  •  
Grade
  •  
During this summer, please select the grade this student will enter in the Fall.
2. Guardian Info
Legal Guardian 1
  •  
  •  
Relationship
  •  
Primary Phone --
  •  
Secondary Phone --
  •  
E-mail
  •  


Legal Guardian 2
  •  
  •  
Relationship
  •  
Primary Phone --
  •  
Secondary Phone --
  •  
E-mail
  •  
Residency
  •  
Please explain any special custody/residency arrangements of which we should be aware.
3. Emergency Contact
In the event we are unable to reach either person listed above, who else should we attempt to contact?
Name
  •  
Please name someone OTHER THAN the two guardians already listed above.
Relationship
  •  
Primary Phone --
  •  
Secondary Phone --
  •  
4. Medical Info
Insurance Provider
  •  
If you do not carry medical insurance, please indicate "none."
Group or Plan ID
  •  
Insurance Policy Holder
  •  
Policy Holder's Date of Birth //
  •  
Physician
  •  
Phone -- ext
  •  
Dentist
  •  
Phone -- ext
  •  
Health Conditions
  •  
Please select all conditions that may require attention while participating in a church event (on or off campus).
  •  
Please provide explanations for all items marked above.
Medications
  •  
List all medications and dosages this child receives on a regular basis. If none, enter "none."
5. Authorization
Select One
  •  
  •  
Media
  •  
Name of Person Granting Authorization
  •  
E-mail
  •  
A PDF copy of this form will be sent to this address for your physical signature.
Signature
  •  
Leave this field blank. You must physically sign the PDF we'll email you in a few minutes.