On rare occasions, an emergency will develop which requires medical care,
hospitalization or surgery for a participant. So that such treatment can be administered
without delay, the Sorority requires that each participant and parent or legal guardian
sign the following statement authorizing Sigma Gamma Rho Sorority, Inc. to secure any
necessary treatment.
In the event that reasonable attempts have been made to contact me at the following
emergency contacts:
Parent/Guardian Name Parent/Guardian Home Phone Parent/Guardian Cell Phone
Alternate Name Alternate Home Phone Alternate Cell Phone
Doctor Name Doctor’s Office Phone Doctor’s Office Alternate Phone
I hereby give my permission and consent to any medical care to include any x-ray
examination, anesthetic, medical, surgical or dental diagnosis or treatment. This is to
include any hospital care needed to be rendered to the minor under general or special
supervision of any physician, dentist
or medical staff of a hospital licensed under the
provisions of the Medical Practice Act,
regardless of whether such diagnosis or
treatment is rendered at the office of said physician or hospital. I understand that the
cost for such treatment is my/our responsibility.
Insurance Name: ___________________________ Subscriber Number: _______________
Group Policy Number: ___________________________________
Please let any allergies or medical conditions:
Please list any medications that your child is taking, prescribed and/or over the counter:
Parent’s Signature Date
