CIRCUS CAMP

Emergency Medical Treatment Authorization Form

Child’s Name____________________________________ Date of Birth___________________

 Address_____________________________ Home Phone______________________________

 *Please list Parent/Guardian names in order in which you would like to be called in case of emergency .

 Parent/Guardian’s Name___________________________ Relationship_________________

 Phone:Home___________________Business_____________________Other_____________

 Parent/Guardian’s Name___________________________ Relationship_________________

 Phone:Home___________________Business_____________________Other_____________

 *If for any reason, I/we cannot be reached, please contact the following person(s) I/we hereby authorize to seek emergency medical or surgical care for my/our child.

 Name______________________________________Relationship________________________

 Phone: Home__________________ Business__________________ Other________________

 Name______________________________________Relationship________________________

 Phone:Home__________________Business___________________Other_________________

 Child’s Physician _____________________________Physician’s Phone_________________

 FoodAllergies/Sensitivities_______________________________________________________

 Existing Medical Problems______________________________________________________

 Medications Child is taking_______________________________________________________

 Additional Comments ___________________________________________________________

 Insurance Coverage: Company____________________ Policy Number_______________

 Subscriber___________________ Employer____________________

Subscriber’s relationship to Child____________________________

 In the event that Circus Camp Staff is unable to reach any of the individuals named above promptly by phone, I/we authorize Circus Camp Staff to seek and secure any emergency medical or surgical care for my/our child. I/We agree to be personally responsible for the payment of such medical expenses incurred. I/We authorize any charges to be billed to my/our insurance company. I/We further authorize the facility at which medical or surgical care is rendered to release all necessary information to my/our insurance company for purposes of reimbursement.

Parent/Guardian’sSignature_______________________________Date__________________