Forms: Emergency Authorization Form

Child's Name
First Last
Child's Birth Date
MM slash DD slash YYYY
Home Phone
Cell Phone
Parent Name
First Last
Parent's Place of Employment
Parent's Business Phone
Parent Name
First Last
Parent's Place of Employment
Parent's Business Phone
Friends or relatives to call if you cannot be reached. Please provide two names, along with their home and cell phone numbers.
Physician(s) to be called in an emergency. Please provide the name and phone number of at least one physician.
Dentist to be called in an emergency. Please provide the name and phone number of the dentist.
Signature

I hereby grant permission for the director or supervisors staff person to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to, the following: 1. Attempt to contact a parent or guardian. 2. Attempt to contact the child's physician. 3. Attempt to contact a parent through any of the persons listed on the emergency information form you completed for us. 4. If we cannot contact you or your child's physician, we will do any or all of the following: (a) call another physician or parademics; (b) call an ambulance; (c) have the child taken to an emergency hospital in the company of a staff member. 5. Any expense under 4, above, will be borne by the child's family.
Date
MM slash DD slash YYYY