Medical Emergency Plan

Medical Emergency Plan

Child's Name: *

First

Middle

Last

Health Card Number: *

Health Condition / Allergy: *

Medications:

Dosage & Type of Auto-Injector:

Procedure if child start showing symptoms:

EMERGENCY CONTACT INFORMATION

We will contact as per the order listed below.

Emergency Contact #1: *

First

Last

Relationship to Member: *

Primary Phone Number: *

Alternate Phone Number:

Email:

Emergency Contact #2: *

First

Last

Relationship to Member: *

Primary Phone Number: *

Alternate Phone Number:

Email:

Emergency Contact #3:

First

Last

Relationship to Member:

Primary Phone Number:

Alternate Phone Number:

Email:

TRANSPORTATION RELEASE OF LIABILITY

I hereby give permission for my child to be transported by BGC Battlefords staff for emergent medical purposes. I understand it is my responsibility to ensure my child’s transportation needs are met at all other times. BGC Battlefords staff will only transport my child in an emergent situation where my child requires immediate medical attention. I acknowledge staff are not liable for any injury incurred during the transport unrelated to the medical situation. I understand I will be notified of the incident and transport at the staff’s earliest convenience - my child’s safety and transport to hospital are priority. Please note the child will only be transported by BGC Battlefords if the child requires immediate medical attention. In all other situations parents/guardians and 911 will be called. Ambulance/medical charges will be at the parent/guardian’s expense.

Transportation Release of Liability - DATE: *

Transportation Release of Liability - NAME: *

First

Last

Medical Emergency Plan Form: *

I have read and given all the correct information for the member on this form. I agree to all conditions and rules regarding Medical Emergency Plan.

Medical Emergency Plan Form - NAME *

First

Last

Acknowledgement:

BGC Battlefords received this form and acknowledges the information. All forms are kept private and updated on our records.

Date & Time

Date

Time

Acknowledgement - NAME

First

Last

Date & Time:

Date

Time

Acknowledgement - NAME

First

Last