EMS Written Authorization Form
Complete this form to provide written authorization for EMS-related permission or approval.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
EMS Provider or Agency Name
*
Your Relationship to the EMS Provider/Agency
*
Please Select
Self
Parent/Guardian
Legal Representative
Authorized Personnel
Other
Reason for Authorization
*
Details of Authorization (Describe what is being authorized)
*
Additional Comments or Instructions
By signing below, I acknowledge and authorize the actions described above.
*
Submit Authorization
Submit Authorization
Should be Empty: