CONSENT FOR EMERGENCY MEDICAL TREATMENT - Child Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO CLASSROOM MATTERS TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR (Child(ren) named below.) THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.
Child(ren) name *
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Parent Initials (serves as signature) *
Your answer
Name and phone number of pediatrician *
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