Medical Care Authorization Form - Calvary Child Care Hawaii

1215 Ala Aolani St. Honolulu, HI 96819

Phone: 808-834-5728

MEDICAL CARE AUTHORIZATION FORM

Date of Birth:

Child’s Name:

_________________________________________

Address: _______________________________________________ Phone: ___________________________________

EMERGENCY CONTACTS:

Parent/Guardian 1: ________________________________________________________________________________

Phone/Email: ____________________________________________________________________________________

Relationship: _____________________________________________________________________________________

Parent/Guardian 2: ________________________________________________________________________________

Phone/Email: ____________________________________________________________________________________

Relationship: _____________________________________________________________________________________

Health

Concerns:

Drug Allergies:

Other Allergies:

Current Medications:

Purpose:

Dosage:

_________________________________________________________________________________________________

Activity Restrictions/Limitations or Chronic Ailments:

Health Insurance Carrier: ___________________________ Policy or Medical Record#:________________________

Family Doctor: ___________________________________

Phone#: ________________________________________

(I/We) hereby give permission for my child to participate in the activities of the Calvary Child Care Center.

(I/We), the undersigned parents/legal guardian having legal custody of ___________________________, a minor, do hereby authorize Calvary Child Care Center as agent for the

undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered

under the general or specific supervision of, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such

diagnosis or treatment at the office of said physician or said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority of power on the

part of our aforesaid agent(s) to give specific consent to any and all such diagnoses, treatment, or hospital care which a physician, meeting the requirements of this authorization,

may, in the exercise of his/her best judgment, deem advisable.

(I/We) hereby authorize any hospital which has provided treatment to the above-named minor to surrender physical custody of such minor to (my, our) above-named agent upon

completion of treatment.

These authorizations shall remain effective for the entirety of my child’s enrollment at Calvary Child Care Center, unless sooner revoked in writing delivered to said agent(s).

Parent/Guardian Print Name:

____________________________________________

Parent/Guardian Signature:

____________________________________________

Date: ___________________