Victory Hill Dorm Emergency Card (CF4078)

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Victory Hill Dorm Emergency Card

The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

Child/Youth

Date of Birth (MM/DD/YYYY)
Personal Health Number
(555) 555-5555
Use the format A1A 1A1

Parent/Guardian

(555) 555-5555
(555) 555-5555

Doctor

(555) 555-5555

Dentist

(555) 555-5555

Consent

I, the undersigned, do hereby give full consent to the Victory Hill Dorm (VHD) to arrange for any form of emergency examination, tests, treatments, or operations for my child that may be deemed necessary or advisable, and to therefore, absolve VHD from any consequence.
I, the undersigned, do hereby authorize the physician, dentists, the hospital staff and employees of the hospital (and persons authorized by such other institutions as may be requested by the hospital), under the direction of a qualified physician or a physician of your choice, to carry out examinations, procedures and treatment deemed necessary and advisable by the attending physician or dentists for the diagnosis, treatment and continuing care of my child.
Date Signed (MM/DD/YYYY)
Parent/Guardian's Signature
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Submission

By clicking submit you will sending your application electronically to the Victory Hill Dorm Manager.
 
If you prefer to print and mail your application, click the PDF button to generate a printable version.
Mail to:
Victory Hill Dorm, c/o Patrick Tarchuk
4334 Victory Street
Burnaby BC V5J1R2
 
Please mark the envelope CONFIDENTIAL.
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