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
(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
************************************************************************
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