Emergency Medical Consent Form - Trojan 6 to 6 Extended Care

Parental Emergency Medical Consent - Trojan 6 to 6

This form must be presented upon admission for treatment. This form allows parents and guardians to authorize the provision of emergency treatment for below named child who becomes ill or injured while under program authority when parents or guardians cannot be reached.

Child's Full Legal Name*
Child's Birthdate*
PARENT(S)/GUARDIAN(S) WITH WHOM THE CHILD RESIDES
Parent 1 - Name*
Parent 1 - Relationship to Child*
Parent 1 - Address*
Parent 1 - Email*
Parent 1 - Cell Phone*
Parent 1 - Home Phone
Parent 1 - Employer*
Parent 1 - Work Phone
Parent 2 - Name
Parent 2 - Relationship to Child
Parent 2 - Address
Parent 2 - Email
Parent 2 - Cell Phone
Parent 2 - Home Phone
Parent 2 - Employer
Parent 2 - Work Phone
EMERGENCY CONTACT PERSON(S)
**Other than parents listed above.** Will only be contacted in emergency, if parents cannot be reached. Must be at least 18 years old.
Contact 1 - Name*
Contact 1 - Relationship to Child*
Contact 1 - Phone Number*
Contact 2 - Name*
Contact 2 - Relationship to Child*
Contact 2 - Phone Number*
PERSONS AUTHORIZED TO PICK UP CHILD
In addition to parents and emergency contacts listed above. Must be at least 16 years old.
1 - Name
1 - Phone Number
2 - Name
2 - Phone Number
3 - Name
3 - Phone Number
Are there any custody or restraining orders for person(s) who may attempt to pick up or have contact with the child while in care at the center? If so, list name(s). Legal document must be supplied to child care coordinator.*
Physician/Dentist Information
Physician Name*
Physician Phone Number*
Physician Address*
Dentist Name*
Dentist Phone Number*
Dentist Address*
Hospital Preference*
Known Allergies*
Current Medications*
Date of Last Tetanus Shot*
Health Insurance Company*
Health Insurance Policy Holder ID*
This consent form will be in effect upon submission of this form and must be updated annually by parent/legal guardian
In the event reasonable attempts to contact have been unsuccessful, I hereby give consent for the administration of any treatment deemed necessary by the doctor or dentist listed below, or if unavailable, another licensed physician or dentist.*
- Yes
I agree to pay all costs and fees as secured or authorized under this consent.*
- Yes
Electronic Signature of Parent or Legal Guardian*
Date*
Email*

Emergency Medical Consent Form – Trojan 6 to 6 Extended Care

Parental Emergency Medical Consent - Trojan 6 to 6

PARENT(S)/GUARDIAN(S) WITH WHOM THE CHILD RESIDES

EMERGENCY CONTACT PERSON(S)

PERSONS AUTHORIZED TO PICK UP CHILD

Physician/Dentist Information

This consent form will be in effect upon submission of this form and must be updated annually by parent/legal guardian