Belle Sherman Enrichment Medical Authorization Form
This form allows parents and guardians to allow for the provision of emergency medical treatment for children who become ill or injured when parents or guardians cannot be reached.
Child Full Name
Your answer
Child's Grade
Child's physician name and phone #
Your answer
Child's dentist name and phone #
Your answer
Parent/guardian name(s) and phone #(s)
Your answer
In the event reasonable attempts to contact me have been unsuccessful, I hereby give consent for the administration of any treatment to my child named above by the medical professionals named above, or in the event the designated practitioners are not available, then by another licensed physician or dentist and/or the transfer of the child to the closest hospital or convenient care center.
I understand that by entering my name below, I am providing an electronic signature as provided for by the Electronic Signatures and Records Act. I understand that paper forms are available upon request.
Parent Electronic Signature (type full name):
Your answer
I understand that by entering my name above, I am signing a legal document.
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