Many hospitals and doctors will not
treat a child without a parent’s consent (unless a matter of life or death). It
is requested that you complete the information below to that if your child
requires a visit to the hospital while under the supervision of the Northeast
Arkansas Living Historians; this will allow the hospital to treat the injury.
EMERGENCY
INFORMATION
Name:
________________________________________________ Sex: ____ male ____ female
Age: ______ Date of Birth:
_______________ SS#: _________________________
Father’s Name: ______________________
Mother’s Name: ________________________
Father’s SS#: ________________________
Mother’s SS#: _________________________
Home Address:
_______________________________________________________________
Home Phone:
__________________________ Work Phone: ______________________
Cell Phone:
______________________________
Another contact person:
_________________________ Relationship: ____________________
Contact Phone: ________________________________
Insurance Name & Phone:
___________________________________________________________
Policy #:
_____________________________ Group #: ________________________
Medical conditions to be aware of:
______________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Medications currently taking:
__________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Allergies: Please list food and/or medication allergies.
________________________________________________________________________
________________________________________________________________________
I give permission for emergency
treatment and/or transportation in the event of injury or illness.
Parent or Legal Guardian Signature:
___________________________________ Date: ____________
Relationship:
______________________________