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

  • 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.
  • PERSONS AUTHORIZED TO PICK UP CHILD

    In addition to parents and emergency contacts listed above. Must be at least 16 years old.
  • Physician/Dentist Information

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