Emergency Medical Treatment Home Enroll Emergency Medical Treatment Emergency Medical Treatment AuthorizationPermission for medical care in parental absence.Child's Full Name Date of Birth Name child answers to: By completing this form, I, parent or guardian of the child named above give my permission to Kessel Kids Child Care & Learning Center, child care provider, to secure and authorize such emergency medical care and treatment as my child might require while under the Provider's supervision. I also authorize the Provider to administer emergency care or treatment as required, until emergency medical assistance arrives. I also agree to pay all the costs and fees contingent on any emergency medical care and treatment for my child as secured or authorized under this consent. as required, until emergency medical assistance arrives. I also agree to pay all the costs and fees contingent on any emergency medical care and treatment for my child as secured or authorized under this consent.NOTE: Every effort will be made to notify parents immediately in case of emergency. In the event of an emergency, it would be necessary to have the following information:Parent or Legal Guardian (1)Name *Email *Primary Phone *Work Phone *Address *Address Line 1Address Line 2CityState / Province / RegionZip / Postal CodeUnited States (US)CountryParent or Legal Guardian (2)Name Email Primary Phone Work Phone Address Address Line 1Address Line 2CityState / Province / RegionZip / Postal CodeUnited States (US)CountryDoctorDoctor's Name Doctor's Phone Doctor’s Address Address Line 1Address Line 2CityState / Province / RegionZip / Postal CodeUnited States (US)CountryPreferred HospitalPreferred Hospital to Contact Phone Preferred Hospital Address Address Line 1Address Line 2CityState / Province / RegionZip / Postal CodeUnited States (US)CountryDentistDentist's Name Dentist's Phone Dentist Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)State / Province / RegionZip / Postal CodeUnited States (US)CountryEmergency ContactsPersons to be contacted during emergency if the parents are unavailable:Name Preferred Phone Relationship Work Phone Name Preferred Phone Relationship Work Phone Medications, Allergeries & VaccinationsPresent medication(s) Known allergies Date of last tetanus Religious Preference Insurance AgreementFather's signature: Mother's signature Date WebsiteSubmit
