Emergency Form

Emergency Medical Treatment Authorization Form

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact them. This form should accompany the child in the event of off-site trips or emergency relocation of the program.
Child's Full Legal Name(Required)
Date of Birth(Required)
Mother's Name
Father's Name
Mother's Address(Required)
Father's Address(Required)
Contact #1 Address
Contact #2 Address
Name any persons who are permitted to pick up your child other than you: (Click the plus to add names.)
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I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for A Joyful Noise Preschool and Childcare to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize A Joyful Noise Preschool and Childcare to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of A Joyful Noise Preschool and Childcare in the exercise of his or her best judgement upon the advice of any such medical or emergency personnel.
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This authorization is effective through
Printed Name:
Printed Name: