Oregon Community Programs

Emergency Release Form


I, , hereby give permission to Oregon Community Programs to call and obtain the service of a physician or hospital for medical care for should an emergency arise. I understand that a conscientious effort will be made to locate me before any action will be taken. I also authorize Oregon Community Programs to involve in certain potentially hazardous activities.

 

(Phone number)

 

(Date)

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Oregon Community Programs https://www.oregoncommunityprograms.org
Signature Certificate
Document name: Emergency Release Form
Unique Document ID: a526f842946ca9b34ad7307464588e1af8a73263
Timestamp Audit
March 26, 2020 10:39 am PDTEmergency Release Form Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85
March 26, 2020 10:53 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:17 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:29 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85