Emergency Medical Treatment. In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of an emergency, if you are unable to reach me at the above numbers, contact: at . Medication my child is taking at present: Allergies: Family Health Plan Carrier Number: Family Doctor: Phone Number: Signature: Date:
Appears in 3 contracts
Samples: Parental/Guardian Consent Form and Indemnity Agreement, Parental Consent and Indemnity Agreement, Parental/Guardian Consent Form and Indemnity Agreement
Emergency Medical Treatment. In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by a doctor the hospital or hospitaldoctor. In the event of an emergency, if you are unable to reach me at the above numbersnumbers listed herein, contact: at . Medication my child is taking at presentName & Relationship: AllergiesPhone: Family Doctor: Phone: Family Health Plan Carrier NumberCarrier: Family Doctor: Phone NumberPolicy #: Signature: Date:
Appears in 3 contracts
Samples: Event Agreement, Event Agreement, Event Participation Agreement
Emergency Medical Treatment. In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of an emergency, if you are unable to reach me at the above numbers, contact: at . (Name) (Phone Number) Medication my child is taking at present: Allergies: Family Health Plan Carrier Number: Family Doctor: Phone Number: Signature: Date:
Appears in 2 contracts
Samples: Parental/Guardian Consent Form and Indemnity Agreement, Parental/Guardian Consent Form and Indemnity Agreement
Emergency Medical Treatment. In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of an any emergency, if you are unable to reach me at the above numbers, contact: at . contact Name/Relation Emergency Phone Number Medication my child is taking at present: Allergies: Family Health Plan Carrier Numbercarrier number: Family Doctor: Phone Number: As Parent or Guardian, I agree to all of the above stated considerations and conditions. Signature: Date:
Appears in 2 contracts
Samples: Parental Consent Form & Indemnity Agreement, Parental Consent Form & Indemnity Agreement
Emergency Medical Treatment. In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by a doctor the hospital or hospitaldoctor. In the event of an emergency, if you are unable to reach me at the above numbersnumbers listed herein, contact: at . Medication my child is taking at presentName & relationship: AllergiesPhone: Family doctor: Phone: Family Health Plan Carrier NumberCarrier: Family Doctor: Phone NumberPolicy #: Signature: Date:
Appears in 1 contract
Samples: Event Agreement
Emergency Medical Treatment. In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of an emergency, if you are unable to reach me at the above numbers, contact: ________________________________________________ at _. Medication my child is taking at present: Allergies: Family Health Plan Carrier Number: Family Doctor: Phone Number: Signature: Date:
Appears in 1 contract
