Tag: Case

Here’s a Neftaly Emergency Contact Information form to collect essential details in case of a medical emergency during extreme sports activities:

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Neftaly Emergency Contact Information

Participant Information:

1. Full Name:
   (First Name, Last Name)
2. Date of Birth:
   (MM/DD/YYYY)
3. Activity Participation:
   • Skydiving
   • Bungee Jumping
   • Zip-lining
4. Primary Phone Number:
   (Mobile Number)
5. Secondary Phone Number (optional):
   (Alternate Contact Number)

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Emergency Contact 1 (Primary Contact)

1. Full Name:
   (First Name, Last Name)
2. Relationship to Participant:
   (e.g., Parent, Spouse, Sibling, Friend)
3. Phone Number (Mobile):
   (Mobile Number)
4. Phone Number (Home or Work):
   (Optional)
5. Alternate Contact Number (optional):
   (Alternate Mobile/Work/Home Number)

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Emergency Contact 2 (Secondary Contact)

1. Full Name:
   (First Name, Last Name)
2. Relationship to Participant:
   (e.g., Parent, Spouse, Sibling, Friend)
3. Phone Number (Mobile):
   (Mobile Number)
4. Phone Number (Home or Work):
   (Optional)
5. Alternate Contact Number (optional):
   (Alternate Mobile/Work/Home Number)

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Medical Information (Optional but Helpful)

1. Does the participant have any known medical conditions that emergency responders should be aware of?
   • Yes
   • No
     If yes, please specify:
2. Does the participant have any allergies (e.g., food, medications, insects)?
   • Yes
   • No
     If yes, please specify:
3. Current Medications (if applicable):
4. Primary Care Physician’s Name:
   (If applicable)
5. Physician’s Phone Number:
   (If applicable)

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Consent for Emergency Medical Treatment

I, the undersigned, authorize Neftaly staff or medical personnel to seek immediate emergency medical treatment for the participant listed above in the event of an injury or health emergency. I understand that every effort will be made to contact the provided emergency contacts as quickly as possible.

• I consent to emergency medical treatment in case of injury or health emergencies.

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Participant Signature:

I acknowledge that the information provided above is accurate to the best of my knowledge. By signing this form, I authorize the Neftaly staff to act in the event of an emergency.

Participant Signature: ___________________________
(Participant’s signature or typed name for consent)
Date: _____________________

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For Participants Under 18 Years of Age:

If the participant is under 18, the form must be signed by a parent or legal guardian:

Parent/Guardian Name: _________________________
Parent/Guardian Signature: ______________________
Date: _____________________

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This Emergency Contact Information form ensures that Neftaly has the necessary contact details in case of a medical emergency and allows for quick action if the participant requires immediate treatment. It also provides relevant health information that can help emergency responders assess the situation quickly.