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

ADDRESS PHONE

FAMILY PHYSICIAN PHONE

DATES DURING WHICH RELEASE IS GRANTED:

FROM TO

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)

Date