ST. ROSE OF LIMA EXTENDED DAY PROGRAM
EMERGENCY TREATMENT FORM
Fill out, (one for each child) print out, sign and return to EDP
TO WHOM IT MAY CONCERN:
As a parent and/or guardian of , a minor, I herewith authorize treatment by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.
NAME OF PARENT OR GUARDIAN
FAMILY PHYSICIAN PHONE
DATES DURING WHICH RELEASE IS GRANTED:
SPECIFIC MEDICAL ALLERGIES, CHRONIC ILLNESS OR OTHER MEDICAL CONDITIONS STAFF SHOULD BE AWARE OF:
OTHER CONTACT IN CASE OF AN EMERGENCY
NAME PHONE RELATIONSHIP
This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.
(Father, Mother, Legal Guardian)