Community Connections

Berlin, Calais, East Montpelier, Middlesex, Montpelier, Worcester

Bringing School and Community Together

Girls/Boyz First! Mentoring Medical Emergency Form

In the event of a medical emergency, I give my permission for medical staff to

treat my daughter/son,___________________. Her/his primary physician is _________________________________Her/his insurance information is:

Insurance company____________Group #___________________Policy Number__________________

Policy holder’s name_________________________.

Any allergies_______________________________________________

Medications currently taking _______________________________________

_____________________________________________________________

I can be reached at the following number: ______________home _______________work _____________cell phone

Emergency Contacts:

______________________Phone_________________ Relationship to mentee

______________________Phone_________________ Relationship to mentee

______________________Phone__________________ Relationship to mentee