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)

  • PERSONS AUTHORIZED TO PICK UP CHILD

  • Physician/Dentist Information

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