Emergency Form

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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)
Gender
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.)
MM slash DD slash YYYY
Consent
MM slash DD slash YYYY
This authorization is effective through
Printed Name:
Printed Name: