Emergency Medical Care Authorization Form printable pdf download

Emergency Medical Care Authorization Form

Emergency Medical Care/Authorization Form

In order to meet all legal requirements, I hereby authorize any representative of Shawnee Presbyterian

Preschool and Children's Day Out to give consent for any and all necessary emergency medical care

for my child (name)_____________________________________________

while said child is in said

individual's custody.

___________________

____________________________________

Date

Signature of Parent or Guardian

State of:

Kansas

)

County of:

Johnson

)

Before me, the undersigned authority, on this day personally appeared

__________________________________ known to be the person whose name is subscribed above

acknowledged to me that he/she executed the same for the purpose therein expressed.

Sworn and subscribed before me this ____________ day of ___________________, 20____

( S E A L )

____________________________________

Notary Public and for _________ County,

Kansas. My commission expires _________

Physician ______________________________

Address__________________________________

Phone __________________________________

Hospital Preference _______________________________________________

Do you have health insurance? yes/no

Policy Name and #__________________

Do you receive medical assistance? yes/no Program and Card # _________________

Is child eligible for military medical care? yes/no

ID. # _______________________

Child's drug allergies:

Last Tetanus Toxoid:

Authorized Person(s) to Pick Up Child

The following people have my permission to pick up my child.

NAME

PHONE

C:\WP51\PRESCHOOL\MEDICAL.RL

Emergency Medical Care Authorization Form