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CAMP MONROE PO BOX 475 MONROE NY 10949 845-782-8695

845-782-2247 (FAX) 2012 STAFF EMERGENCY CARE FORM

This form is to accompany the staff member named in the event that outside medical or emergency treatment is necessary .

NAME OF STAFF MEMBER________________________________________________________________ ADDRESS______________________________________________________________________________ CITY_________________ STATE___________ ZIP_________ PHONE_____________________________ BIRTHDATE_________________________

AGE (as of June 21, 2012)___________________

Name of person to be contacted in emergency. NAME____________________________________ PHONE______________________________________ RELATIONSHIP__________________________________________________________________________ FAMILY DOCTOR_______________________________ PHONE__________________________________ ALLERGIC TO____________________________________________________________________________ I hereby give permission and voluntarily consent to any of the emergency room physicians, qualified personnel, staff of any accredited hospital, or any duly licensed physician to administer anesthetics and perform such diagnostic treatment or medical or operative procedures, upon me as may be deemed necessary. I fully understand this consent. STAFF MEMBER'S SIGNATURE_____________________________________________________________ NOTARY SEAL

Hospitals require the following information upon arrival. Are you covered by hospitalization insurance?______________ NAME OF INSURANCE COMPANY___________________________________________________________ NAME POLICY IS LISTED UNDER________________________________Date of Birth__________________ Social Security number of Policy Holder______________________Employer of Policy Holder______________ POLICY OR GROUP NUMBER__________________________If group, NAME OF GROUP_______________ If you have additional coverage: NAME OF INSURANCE COMPANY___________________________________________________________ NAME POLICY IS LISTED UNDER________________________________Date of Birth__________________ Social Security number of Policy Holder______________________Employer of Policy Holder______________ POLICY OR GROUP NUMBER__________________________If group, NAME OF GROUP_______________ IT IS VERY IMPORTANT THAT WE HAVE A COPY OF YOUR MEDICAL INSURANCE CARD (FRONT AND BACK) as well as information as to your company's filing procedure for a doctor's visit and prescriptions. Include any insurance numbers we need and a copy of your prescription plan cards as well.


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