MIME-Version: 1.0 Content-Location: file:///C:/1A74CAAD/EmergencyMedicalForm.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Richmond Area Chrysalis Community

Richmond Area Chrysalis Community

EMERG= ENCY MEDICAL INFORMATION

 

Name: _________________________________________ Grade : ___________ Birth date: _______________

 

Address: ____________________________________________________ Telephone: (      ) ____-___= _______

 

Parent’s name: ________________________________________________Telephone: (     ) ____-_________= __

 

Father’s employer: _____________________________________________Telephone: (     ) ____-_________= __

 

Mother’s employer: ____________________________________________ Telephone: (     )____-__________= _

In case neither parent can be located notify:

Name: ______________________________________________________ Relationship: __________________

 

Address: _____________________________________________________ Telephone: (     ) ___-__________= _

 

Preferred Physician: _____________________________________________Telephone: (     ) ___-__________=

 

Preferred Dentist: ______________________________________________Telephone: (     ) ____-_________=

EMERG= ENCY MEDICAL AUTHORIZATION

Purpose: To enable parents and guardians to authorize the emergency treatment for children who become ill or injured while under Richmond Area Chrysalis authority, when parents or guardians cannot be reached. <= /p>

PART I OR PART II MUST= BE COMPLETED.

PART I G= RANT CONSENT

In the event attempts to contact parents/guardians are unsuccessful I give my consent for (1) any treatment deemed necessary by the preferred physician or preferred dentist or in the event my preferred physician/dentist is not available, by another licensed physician or dentist and (2) the transfer of= the child to the hospital. This authorization does not cover major surgery unle= ss medical opinions of two other licensed physicians or dentist concur in the necessity of such surgery. This authorization is valid for the current year= or until such time as I withdraw this authorization.

Date: ____________________________ Parent/Guardian Signature: _________________________________

PART II REFUSAL TO CONSENT=

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  I do not give my consent to emerge= ncy treatment of my child in the event of illness or injury requiring emergency medical treatment. I wish the Richmond Area Chrysalis Authorities to take no action but instead to:

______________________________________________________________________= ____________________

 

Date: ____________________________ Parent/Guardian Signature: __________________________________

PLEASE R= ETURN THIS TO RICHMOND AREA CHRYSALIS REGISTRAR  A= .S.A.P.

THIS FOR= M MUST BE COMPLETED AND WILL BE ON FILE WITH THE RICHMOND AREA CHRYSALIS COMMUNITY

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SERIO= US HEALTH PROBLEMS

Allergies: _______________________________________ Current Medications and treatments: ____________

______________________________________________________________________= ___________________

Serious Health Conditions: ___________________________________________________________________

______________________________________________________________________= ___________________

 

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