Park Place Parents Association
DBA Green Tree Early Childhood Center
CONSENT TO MEDICAL CARE AND TREATMENT OF MINOR CHILDREN
If your child has a medical condition such as allergies (food or other), asthma, seizure disorder etc.please notify administration. You are required to have your health care provider sign and return specific forms that will be given to you.
I ______(the natural parent or legal guardian) hereby give permission that my child, ______, may be given emergency treatment to include first aid and CPR by a qualified child care staff member at Green Tree Early Childhood Center. I further authorize and consent to medical, surgical, and hospital care, treatment and procedures to be preformed for my child, by my child’s regular physician. When my child’s physician cannot be reached, I authorize and consent to medical, surgical, and hospital care by a licensed physician or hospital deemed immediately necessary or advisable by the physician to safeguard my child’s health and I cannot be contacted. I waive the right to informed consent for such treatment. I will provide my own health and accident insurance or expenses for my child. I understand that my signature below releases Green Tree Early Childhood Center, staff, and representatives from all legal liability for emergency treatment and medical care.
I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I grant permission for my child’s health care provider and the director of Green Tree Early Childhood Center to share information concerning my child.
Parent Signature: ______Date: ______
Park Place Parents Association
DBA Green Tree Early Childhood Center
HEALTH HISTORY
Child’s Physician: ______Phone: ______
Address: ______
Date of Last Physical Examination: ______
If your child has a medical condition such as allergies (food or other), asthma, seizure disorder etc.please notify administration. You are required to have your health care provider sign and return specific forms that will be given to you.
Health or Developmental Concerns or Issues: ______
______
Other Medical Condition(s): ______
______
Allergies (please request required forms to be completed by health care provider provider)______
______
Current Medications: ______
______
Preferred Hospital: ______Phone: ______
Address: ______
Child’s Dentist: ______Phone: ______
Address: ______
Date of Last Dental Visit: ______
Parent Signature: ______Date:______Daytime Phone:______
CJP
8/14/2007