J4KC 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
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Signature
Should be Empty:

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