AUTHORIZATION AND CONSENT FORM

I understand that every effort will be made to contact me in the event of an emergency

requiring medical attention for my child, ___________________________________

(Name of child)

However, if I cannot be reached I hereby authorize the __________________________

(Name of center)

to transport my child to the _________________________________________ Hospital

(Name of hospital)

(or nearest hospital) and to secure for my child the necessary medical treatment.

I understand the staff members at the ___________________________ are trained in the

(Name of center)

basics of First Aid and I authorize them to give my child first aid when appropriate.

________________________________________ _______________

Parent / Guardian Signature Date

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EMERGENCY RELEASE FORM

When I cannot be reached in the case of an emergency I hereby authorize the following

person(s) to pick-up my child from the __________________________:

(Name of center)

1. Name:____________________________________________________

Address:___________________________________________________

Phone:__(____)_____________ Driver's License #_________________

Relationship to child:___________________________________________

2. Name:____________________________________________________

Address:___________________________________________________

Phone:__(____)_____________ Driver's License #_________________

Relationship to child:___________________________________________

____________________________________________ ________________

Parent / Guardian Signature Date