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Victory Hill Dorm Emergency Card (CF4078)

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Victory Hill Dorm Emergency Card

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

Last Name

First Name

Date of Birth (MM/DD/YYYY)

Personal Health Number

Aboriginal/Indigenous Band Status Number

Home Phone Number

Address

City

Postal CodeUse the format A1A 1A1

Parent/Guardian

Name

Work Phone Number

Cell Phone Number

Doctor

Family Doctor

Office Name

Office Phone Number

Dentist

Dental Plan Number

Office Name

Office Phone Number

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.

Parent/Guardian's Name

Date Signed (MM/DD/YYYY)

Parent/Guardian's Signature

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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The information on this form is collected under the authority of Sections 26(c) and 27(1)(c) of the Freedom of Information and Protection of Privacy Act to help us assess and respond to your enquiry. Questions about the collection of information can be directed to the Manager of Corporate Web, Government Digital Experience Division.

I consent

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