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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