J4KH LIC 627: Consent for Emergency Medical Treatment

CONSENT FOR EMERGENCY MEDICAL TREATMENT -Child Care Centers Or Family Child Care Homes
Name of Child*
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
FACULTY NAME TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME OF CHILD* THIS CARE MAY BE GIVEN UNDER
WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL-BEING OF THE CHILD NAMED ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:*
Please type NONE if there is none.
HOME ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE*
WORK PHONE*
Name*

First NameLast Name
Parent / Guardian Email*
You will receive a copy of this PDF you just filled out thru this email address.
DATE*

MonthDayYear
Date
Parent / Guardian Signature*

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CONSENT FOR EMERGENCY MEDICAL TREATMENT -Child Care Centers Or Family Child Care Homes