Common use of REFUSE TO CONSENT Clause in Contracts

REFUSE TO CONSENT. (Do not complete if you completed Part 1) I do NOT give consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take NO action or to: Signature of Parent/Guardian Date Monroe Schools Emergency Early Dismissal Form Child’s Name Grade Homeroom _ Check the appropriate box(es). My child will follow the regular dismissal. I will pick my child up if early dismissal is announced. Parent’s Signature Date Phone number where parents can be reached: I give permission for my child to be released to the following individuals in the event that school would be dismissed early and I am not available to transport my child. Name Address Phone Relationship to child Name Address Phone Relationship to child Monroe Local Schools Health History Form Please Print and use black or blue ink. Student’s name Male Female Date of birth Family Health History Please list allergies, heart problems, diabetes, cancer, or other serious health conditions. Father Mother Brothers and Sisters Birth and Developmental History: Did the mother have any unusual physical or emotional illness during this pregnancy? YES NO Was infant born full term? YES NO Did infant have sickness or problems? Briefly explain illness or problems. YES NO How does the child’s development compare to other children, such as his or her brothers/sisters or playmates? About the same Delayed Advanced