Common use of AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION Clause in Contracts

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION. In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to: Name of Physician: Address: Ph.#: Name of Emergency Medical Care Facility: Address: Ph.#: I give consent for the facility to secure any and all necessary emergency medical care for my child. Signature – Parent or Legal Guardian List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of (if none state n/a): Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (000) 000-0000 (voice) of (000)-000-0000 (TTY).

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION. In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to: Name of Physician: Address: Ph.#: Name of Emergency Medical Care Facility: Address: Ph.#: I give consent for the facility to secure any and all necessary emergency medical care for my child. Signature – Parent or Legal Guardian List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of (if none state n/a): Texas Dept of Family and Protective Services ADMISSION INFORMATION Form 2935 Oct 2008 / Pg 2 of 3 Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (000) 000-0000 (voice) of (000)-000-0000 (TTY).