All-Treasure Night Participant Emergency Information

Treasure Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Treasure Phone Number

Area Code Phone Number
Email
example@example.com
Emergency Contacts
Emergency Contact #1

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Relationship to Treasure
Emergency Contact #2

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Relationship to Treasure
Legal Guardian Information
Is this Treasure their own legal guardian?

Yes (please leave the below guardian information blank) No (please leave the below guardian information blank)
Does this Treasure have a legal guardian?

Yes (please provide the legal guardian information below) No (please leave the below guardian information blank)
Guardian Name

First Name Last Name
Relationship to Treasure
Guardian Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Guardian Phone Number

Area Code Phone Number
Guardian Email
example@example.com
Medical and Safety Information
Does Treasure need assistance in restroom? If yes, please explain:

List all Allergies/Reactions
Prone to Seizures?

Yes No
If yes, please attach seizure protocol

Browse Files

Cancel of
Diabetic?

Yes No
Special Instructions
Do you have a preferred hospital in the event of an emergency?
Emergency Authorization, Liability&Publicity Release

Quiet Waters Outreach is dedicated to providing superior services and has taken reasonable precautions in planning and supervising activities in the past and in the future. In the unlikely event of an accident, I grant permission for the trained supervisors of Quiet Waters Outreach to seek any medical assistance necessary for the health and well-being of the participant listed below. I would request that if medical assistance becomes necessary, I would be contacted immediately or as soon as reasonably possible at the address or telephone number listed above. I further grant permission for Quiet Waters Outreach to use the above listed participant's picture, voice, and words in any marketing materials to promote Quiet Waters Outreach. I have read and understand the information above.
Signature of Self/Guardian *

Clear
Date

Month Day Year
Date
Witness to Treasure's Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Treasure Information