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Lowpoint-Washburn
C.U.S.D #21
21st
Century
Community
Learning
Center
Grant
After-School
Program
EMERGENCY MEDICAL CONSENT
This
form must be presented upon admission for treatment.
Child’s
Full Name:_________________________________ Birth Date:______________
In
the event that my child (listed above) requires medical and/or surgical
care while I am out of the city or unable to be reached, I hereby give my
consent for medical and/or surgical treatment to:
(Child’s
name)___________________________Hospital/Doctor:____________
or
his/her designee to provide this care.
I agree to pay all costs and fees contingent for any emergency
medical care and/or treatment for my child as secured or authorized under
this consent. (The
After-School Program states that every effort will be made to notify
parents/guardians immediately in case of emergency).
INFORMATION:
Doctor:______________________
Phone:___________________
Address
of Doctor:__________________________________________
Date
of last Tetanus shot:_____________________________________
Allergies:_________________________________________________
Medication:_______________________________________________
Hospital
Preference (optional):_______________________________________________
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This
consent will be in effect beginning on
(date)________________________________
And
continue while the child is enrolled in this facility.
Signature
of Parent/ Guardian
Date
Signature
of Parent/Guardian
Date
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