Parental Exigency Medical Consent Form
Whenever your child converts ill or injured on your absence, you want to make sure that he/she will get the right attention.
IN THE CASE THAT MY CHILD (LISTED SUPRA) MAY POSTULATE MEDICAL AND/OR SURGICAL ATTENTION WHILE I AM OUT OF THE CITY OR NOT ABLE TO BE ARRIVED AT, I HEREWITH APPLY MY CONSENT FOR MEDICAL AND/OR SURGICAL TREATMENT TO ____________________INFIRMARY AND PHYSICIAN_______________________ OR HIS/HER DESIGNEE TO SUPPLY THIS ATTENTION. I ACCORD TO ANTE UP ALL THE COSTS AND FEES DEPENDENT ON WHATEVER EXIGENCY MEDICAL ATTENTION AND/OR TREATMENT FOR MY CHILD AS SECURED OR EMPOWERED NETHER THIS CONSENT. (PROJECT FOR NEIGHBORHOOD AFTERCARE STATES THAT EVERY ATTEMPT WILL BE MADE TO GIVE NOTICE PARENTS/GUARDIANS DIRECTLY IN EVENT OF EXIGENCY.)
MEDICAL INFORMATION
Physician___________________Address_____________________________________________
Phone Number ____________Last Tetanus _________Allergic Reactions_________________________
Medication _________________________ Particular Demands_______________________________
Insurance Co. ______________________________ Policy Holder’s I.D.____________________
This Consent Will Be Effective Starting _____________________And Will Keep on whilst the Child Is Recruited In This Programme.
___________________________________________ __________________________
MEDICATION AUTHORIZATION
Please notice: no medication will be administered to your child if this form has not been finished. A copy of the prescription or physicians remark must be attached.
Child’s Full Name__________________________________________________________
Name of Medication________________________________________________________
Date to Begin________________________Through_____________________________
Dosage and Times at Programme _____________________________________________
Please administer the supra medication:
Signature of Parent/Guardian _________________________Date_______________
Project for Neighborhood Aftercare doesn't know apart on the base of race, colour, national origin, sex, handicap, or years.
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