Download parent/guardian consent and emergency treatment form

PARENT/GUARDIAN CONSENT AND EMERGENCY TREATMENT FORM
Is anyone legally restricted from being in contact with your child
If yes, who:
 Yes
 No
(Place legal documentation in Family files)
Child’s Name (Last, First)
Birth Date (Child)
Center
Home Address
Parent/Guardian 1
Relationship
Parent/Guardian 1 Primary Language:
Parent/Guardian 1 Phone
Phone (Massage/Cell)
Employer (Parent 1)
Employer Phone
Parent/Guardian 2
Relationship
Parent/Guardian 2 Primary Language:
Parent/Guardian 2 Phone
Phone (Message/Cell)
Employer (Parent 2)
Employer Phone
Emergency Medical Contact Name (Last, First)
Relationship to Child
Phone
Child’s Health Care Provider
Phone
Medical Problems/Allergies
Medications (if any)
Name of Child’s Insurance Plan
Child’s Medicaid Patient Identification Code (PIC) or Private Insurance Number
Child’s Dentist
Phone
I hereby give permission for my child to receive emergency treatment including first aid and CPT by a qualified staff member. I further
authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by my child’s regular
health care provider, or when that health care provider cannot be reached, by a licensed physician or hospital when deemed immediately
necessary or advisable by the physician to safeguard my child health if I cannot be contacted.
I also give permission for my child to be transported by ambulance, aid care or the above named alternate persons to an emergency center
for treatment. If my child becomes ill or injured at Head Start and I or the above mentioned alternates cannot be reached or provide
transportation for my child, I give permission for my child to be transported home as usual by school district or Head Start transportation.
Signature of Parent/Guardian
Date
Signature of Parent/Guardian
Date
1: print page 1 and 2 back to back
HS Forms/Parent Guardian Consent/Emergency Treatment Form
07/2008
Permission is hereby granted for my child, __________________________________________
_____________________________________to be released to the following individuals for the
current program year. Persons listed below must show proper identification for the above
named child will be released from center or bus.
Date
Name
Relationship to Child
Phone #
Parent Initials
The following sibling/or other child over the age of 12 years may receive my Head Start child from the bus. Picture identification must be
sown to receive child from the bus or center.
Date
Name
Relationship to Child
Phone
Parent Initials
CONSENT FOR SERVICES
I give my consent for Puget Sound ESD Head Start to perform the following services form my child, while the child is enrolled in Head Start
(please initial):
Walking field trips (address will be posted 24 hours prior to)
Development screenings and assessments
State Child Profile Immunization
Parent/Legal Guardian Signature
Initials
Date
Parent/Legal Guardian Signature
Initials
Date
Interpreter Signature
Date
2: print page 1 and 2 back to back
7/2008