NCE Medical Release
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This document contains health and emergency contact information for a child participating in the NorCal EXTREME program. It lists the child's name, date of birth, parents/guardians' names and contact details, as well as alternative emergency contacts. Health insurance details, allergies, medications, and authorization for emergency medical treatment are also provided. The parents/guardians sign to grant permission for emergency medical care if they cannot be reached.
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NCE Medical Release
- 1. NorCal EXTREME Health Information and Release To be filled out by parent or guardian. Please print in ink or type. Childs Name: (Last)________________________ (First)_______________(MI)___ DOB______ Name of parent(s)/guardian(s):________________________________________________ In case of emergency, contact Mother: Day________________________ Eve____________________ Cell/pager________________ Father: Day________________________ Eve____________________ Cell/pager________________ If persons named above cannot be reached, contact First contact: Name___________________________ Relationship___________________________ Day________________________ Eve____________________ Cell/pager________________ Second contact: Name___________________________ Relationship___________________________ Day________________________ Eve____________________ Cell/pager________________ Health insurance information: Health plan name:_____________________________ Group or plan number:__________________ Medical record number:________________________ Physician name:________________________ Contact number:______________________________ Other:________________________________ Allergies, other health problems:__________________________________________________________ Medications taken regularly: (1)_____________________________________Self administered?______ (2)_____________________________________ Self administered?______ All medications to be administered by NorCal EXTREME adults must be in the original containers with dosage clearly marked. The adults accompanying the NorCal EXTREME team have my/our permission to authorize emergency medical treatment at a hospital/clinic/physician office for my/our son in the event that I/we or our authorized contacts listed above cannot be reached to verbally authorize such treatment or if verbal authorization is not acceptable to the provider. Date:__________________________ Date:__________________________ _______________________________ _______________________________ Mother/guardian signature Father/guardian signature