Emergency Contact and Medical Release Form Name: * First Name Last Name Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth: * MM DD YYYY Phone: * (###) ### #### Parent/Family Member 1: * Please type in "N/A", if not applicable. First Name Last Name Parent/Family Member 1 Phone: (###) ### #### Parent/Family Member 1 Email: * This parent will receive Oak Valley event news. Parent/Family Member 1 Address: Include if different than your address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Family Member 1 Employment: * Please type "N/A" if not applicable. Parent/Family Member 2: * Please type "N/A" if not applicable. First Name Last Name Parent/Family Member 2 Phone: (###) ### #### Parent/Family Member 2 Email: * This parent will receive Oak Valley event news. Parent/Family Member 2 Address: Include if different than your address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Family Member 2 Place of Employment: * Please type "N/A" if not applicable Emergency Contact Name: * First Name Last Name Emergency Contact Phone: * (###) ### #### Relationship to Self: * Prescription Medication(s): * Please type "N/A" if not applicable. Allergies: * Food/medicines/etc. Please type "N/A" if not applicable. Medical Conditions: * Please type "N/A" if not applicable. Physician's Name: * Please type "N/A" if not applicable. First Name Last Name Physician's Phone: Please type "N/A" if not applicable. (###) ### #### Medical Insurance: * If uninsured, please type "uninsured" Policy Number: Name of insured/responsible party: * If self, please type "Self". If uninsured, please type "N/A". Employer group/name: In the event of a serious medical emergency, I authorize Oak Valley College, its employees, and/or other agencies (collectively, the College) to secure medical transportation or treatment on my behalf. I understand that the College is not required to obtain medical transportation or care for me. I understand that the College will attempt to contact one of the individuals I have designated as an emergency contact. I authorize the College to release the information on this form to health care providers for securing health care services for me. I understand and agree that I am responsible for all expenses, fees, or costs incurred as a result of medical transportation or care secured for me by the College. I understand and agree that the College is not liable for any injury or damages that may occur as a result of medical treatment that I may receive. * First Name Last Name Thank you!
