Long Beach Japanese Language School Emergency Treatment Consent Form
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO LBJLS TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.), DENTIST (D.D.S.) OR QUALIFIED MEDICAL PERSONNEL. FOR . THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING CHILD NAMED BELOW:
Student name
Your answer
Does your child have any medication allergies?
List Medication Allergies (if any)
Your answer
Does your child have any food allergies?
List Food Allergies (if any)
Your answer
Please see below note concerning food allergies:
During the recess time, snacks will be provided. The snacks are provided by volunteers and it is difficult to monitor precisely if they may contain food allergies items. Therefore, we would encourage you to provide a snack the volunteers can use as a back up for times when the other snacks may contain concerned ingredients or parents with children with allergies can provide their own snacks to be sure of avoidance.
Home address (Street, Apt#)
Your answer
City
Your answer
Zipcode
Your answer
Primary phone number
Your answer
Secondary phone number
Your answer
Emergency contact and phone number
Your answer
Parents /Guardian Name
Your answer
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms