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
lock iconUnique Document ID: 325a96f558817b11b300071d73c7cc3f6930b03d
Timestamp Audit
March 26, 2020 10:39 am PSTEmergency Release Form Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85
March 26, 2020 10:53 am PSTIntake 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 PSTIntake 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 PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 6, 2020 1:56 pm PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 6, 2020 1:56 pm PSTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:10 am PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:10 am PSTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:55 am PSTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:55 am PSTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 13, 2020 11:32 am PSTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85