Form Ccl 010 - Authorization For Emergency Medical Care

Kansas Department of Health and Environment

CCL 010

Rev. 6/2015

Bureau of Family Health

1000 SW Jackson, Suite 200

Topeka, KS 66612-1274

Child Care Program:

(785) 296 -1270 Fax: (785) 296 -0803

Website:

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical

facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-

582(e)(2).

Name of facility exactly as stated on the license.

License #

I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or

____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the

above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________

___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s

custody between the dates of ___________________________ and ____________________________.

MM/DD/YYYY

MM/DD/YYYY

Signature of Parent or Guardian

Date Signed

Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic.

Date Signed

Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.

State of Kansas

County of ________________________

Signed or attested before me on ____________________ by______________________________________________.

MM/DD/YYYY

Name of Person

(Seal, if any.)

_______________________________________________

Signature of notarial officer

______________________________________________

Title (and Rank)

My appointment expires: __________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency:

Is child covered by health insurance?  Yes  No

If yes, complete the following:

Health Insurance Policy Name _________________________________________ Policy Number ______________________

Medical Assistance Program ____________________________________________ Card Number________________________

Military Medical Care I.D. Number ___________________________________________________________________________

If known, date of last Tetanus inoculation: __________________________________

THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE

AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST

ALSO BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.