Emergency Information

Which location are you submitting data for?  


Emergency Contact (if Parent(s) or Guardian(s) cannot be reached)

AUTHORIZED FOR CHILD RELEASE (do not add Parents or Emergency Contacts to this list)

Adult’s Name: Home/Cell Number: Work Number:

PARENTAL PERMISSION FOR EMERGENCY TREATMENT

I give my permission that in case of an emergency, if I am not immediately available, the physician on duty may hospitalize and secure proper treatment for ordering injection, anesthetics or surgery for my child. I also give my permission for my child to be transported to the emergency department of the nearest hospital with no liability on the driver’s part.

2018-08-21