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Emergency Medical Consent Form
Child Details
Child's First Name
*
Child's Last Name
*
Child's Date of Birth
*
Child's Gender
*
*
-- Select Gender --
Male
Female
Transgender
Other
Prefer not to say
Child's Race
*
*
-- Select Race --
African American or Black
White
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Prefer not to say
Child's Ethnicity
*
*
-- Select Ethnicity --
Hispanic or Latino
Not Hispanic or Latino
Prefer not to say
Child's School Name
*
*
-- Select School Name --
Skyline Middle School
Stanton Middle School
Parent/Guardian Details
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Address line 1
*
Parent/Guardian Address line 2
Parent/Guardian City
*
Parent/Guardian State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Parent/Guardian Zip Code
*
Parent/Guardian Email address
*
Phone Type
*
(Mobile Number is preferable.)
Mobile
Landline
Parent/Guardian Phone Number
Format: (302) 123-1234
+1
Relationship to patient
*
*
-- Select Relationship --
Brother
Child
Father
Grandchild
Grandparent
Guardian
Mother
Power of Attorney
Sister
Unknown
Ward of court
Yes
No
Would you like to add additional Parent/Guardian Information?
*
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Address line 1
*
Parent/Guardian Address line 2
Parent/Guardian City
*
Parent/Guardian State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Parent/Guardian Zip Code
*
Parent/Guardian Email address
*
Phone Type
*
(Mobile Number is preferable.)
Mobile
Landline
Parent/Guardian Phone Number
Format: (302) 123-1234
+1
Relationship to patient
*
*
-- Select Relationship --
Brother
Child
Father
Grandchild
Grandparent
Guardian
Mother
Power of Attorney
Sister
Unknown
Ward of court
Insurance Information
Yes
No
Do you have insurance?
*
I confirm that I do not have any health insurance.
*
Insurance Type
*
Primary
Company Name
*
Policy Number
*
Group Number
Valid Through
Insurance Card FRONT
Insurance Card BACK
Photo ID/US Driver's Licence FRONT
Photo ID/US Driver's Licence BACK
Yes
No
Do you have secondary insurance?
*
Insurance Type
*
Secondary
Company Name
*
Policy Number
*
Group Number
Valid Through
Insurance Card FRONT
Insurance Card BACK
Photo ID/US Driver's Licence FRONT
Photo ID/US Driver's Licence BACK
Yes
No
Do you have tertiary insurance?
*
Insurance Type
*
Tertiary
Company Name
*
Policy Number
*
Group Number
Valid Through
Insurance Card FRONT
Insurance Card BACK
Photo ID/US Driver's Licence FRONT
Photo ID/US Driver's Licence BACK
Additional Instructions
CareForceMD has my permission to provide emergency medical treatment for my child,
____________
when I cannot be reached or if a delay in reaching my child would be dangerous for him/her.
*
I understand and agree that by typing my name here, I am electronically signing this form.
*
Authorized Person Name
*
Submit
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