Mana O Maui Rugby Club Emergency Plan
IN AN EMERGENCY CALL 911
When you call 911 you should:
• Identify yourself and your exact location (Lahaina Field at Shaw Street and Honoapiilani Highway)
• Explain the situation and nature of the injury (teens playing rugby and ___________, example: one with piror history of epilepsy is having a seizure)
• Stay on the line until the operator disconnects the call.
• A team administrator or coach should stay with the injured player until his or her parents arrive. This means going with the ambulance if a parent is not at field when ambulance leaves with player, even if it means coach must leave while match still in progress or match must be called early if no assistant coach is on scene to supervise.
If an ambulance comes to transport someone all trips go to
Maui Memorial Hospital Emergency Room
Additional Phone Numbers:
Maui Memorial Hospital: 244-9056 (main switchboard)
Emergency Room 242-2343
Admitting 242-2032
Fire Department: Phone 911
Ambulance Service (American Medical Response): Phone 911
Police Department: 911
Coach Jack's Cell: 344-7191
Earthquake or Tsunami Civil Defense Recommendation
If feel strong shake that makes standing difficult IMMEDIATELY SEEK HIGHER GROUND. DO NOT WAIT FOR SIRENS TO SOUND AS LOCAL QUAKE MAY GENERATE TSUNAMI NEARER THAN SIREN SENSORS.
If Siren sounds go to and STAY ON HIGHER GROUND it MAY TAKE MORE THAN 3 HOURS BEFORE THE THREAT IS OVER.
Here is the medical safety form that is required for players and suggested for anyone driving players or other participants to practices or matches.
AUTHORIZATION FOR EMERGENCY MEDICAL TRANSPORTATION AND/OR TREATMENT FOR A MINOR, OR OTHER PERSON INVOLVED WITH MANA O MAUI RUGB CLUB WHO BECOMES UNABLE TO PROVIDE CONSENT, IN THE EVENT OF AN EMERGENCY
I (we) ____________________________________ (and) __________________________________________ the undersigned parent and/or legal guardian of the minor child _____________________________________, on behalf of my child, or on my own behalf, in the event I am unable or unavailable to provide such a request and authorization at the time of an emergency, do hereby authorize and appoint John J. Breen, volunteer coach of the Mana O Maui Rugby Club and Hilmy Dole, a volunteer administrator of Mana O Maui Rugby Club, or either of them, to request and authorize emergency medical transport and/or treatment, including but not limited to any examinations, diagnostics, tests, studies, imaging, surgery or procedures of any nature, deemed necessary or appropriate by the person taking charge of the care of my child, or me, in the event of an emergency. HOWEVER, this authorization shall be effective ONLY in the event of an emergency, and ONLY if reasonable efforts by the coach, administrator, paramedical, medical, and/or hospital personnel to reach the undersigned and the adult persons designated below have proven unsuccessful in obtaining authorization for emergency medical transportation and/or treatment. I direct and request that efforts be made to contact the adults listed below in the event of an emergency involving my child, or me:
Name Cell Phone Work Phone Home Phone Other Phone Relationship
________________ ___________ _______________ _____________ ___________ ___________
(Parent/Guardian or Adult Authorizing)
________________ ___________ _______________ _____________ ___________ ___________
(Other adult family member or friend of family)
________________ ___________ _______________ _____________ ___________ ___________
(Other adult family member or friend of family)
Information regarding participant for whom this authorization is being provided:
Medical Alert: Allergies: _________________________, Medications: _______________________________
Drug Reactions: ___________________________________________________________________________
Previous Injuries/Illnesses/Surgery: ____________________________________________________________
Current Physical Condition: __________________________________________________________________
Health Insurance Provider & Policy Number: ____________________________________________________
Name of Policy Holder (generally the parent): ___________________________________________________
Name of Primary Physician: __________________________________________________________________
Phone #________________________________________
I (we) understand that I (we) assume all liabilities and expenses for the above. I (we) waive all claims against the above referred to coach, administrator, adults, paramedics, nurses, therapists, physicians, hospitals and their employees, ambulatory care, etc., in connection with the decision for immediate medical transport and/or treatment.
This authorization is valid only from February 1st, 2009 to August 30, 2009, inclusive.
________________________ ___________________________ _________________________
Parent Signature(s) Print Parent Name(s) Date Signed
**Non-minors and emancipated minors must still fill out this form and sign for themselves.