The Bridge Emergency Consent Form

Consent for Emergency Medical Care

I, _________________________________ hereby give my consent for emergency medical/surgical/dental care and treatment necessary in the opinion of the Mentors Matter/ The Bridge Mentoring staff or medical personnel to preserve the health of my child while he/she is participating in the community based Mentors Matter program. I also consent to emergency transportation by ambulance to an appropriate medical facility for treatment.

I understand that I will be contacted as soon as reasonably possible in the event an accident or emergency should occur, and acknowledge that I am responsible for all reasonable charges in connection with any care and treatment rendered.

If I cannot be reached in case of emergency, the following people are authorized to act on my behalf:

Name: ___________________________ Phone: ______________________

Name: ___________________________Phone:_______________________

Print Child’s Name:____________________________ Birth date:______________

Home Address: ____________________________________________________

Home Phone:_________________ Work Phone:_______________

Name of Child’s Doctor: _______________________________

Phone Number: ____________________

Address:___________________________________________________________

Child’s Medications:__________________________________

Child’s Allergies:____________________________________

Name of Health Insurance Carrier:

______________________________________________

Name of Policy Holder: ____________________________ Policy #______________

Parent/ Guardian Signature: ____________________________ Date:_______________

Mentors Matter’s

The Bridge