Please Print Clearly and Return to the Center Office ASAP.

Child’s Name (One Form Per individual:                                                                                                               

Date of Birth:                           

Age as of 6/2014:                    

Grade Entering:                             

Allergies or Medical Concerns? : ________________________________________________                                                                                                                                                                               Parent/Guardian Name(s):                                                                                                                                                               Address:                                                                                                                                                               

City:                                             

State:           

Zip:                    

Phone #:                                          

Secondary Phone #:                                            Email Address:    Emergency Contact Name:             Phone #:                                                                  

How did you hear about PLC’s Program:                

Homecare agency:                                           

EMERGENCY INFORMATION AND MEDICAL AUTHORIZATION

Purpose of the following information: To enable parents and guardians to authorize the provision of emergency treatment for individual who become ill or injured while under center authority, when parents or guardians cannot be reached. FILL OUT ONLY PART I or PART II.

PART I – GRANT TO CONSENT

In the event reasonable attempts to contact me at (phone #)                                           have been unsuccessful, I

hereby give my consent for: (1) The administration of any medical treatment deemed necessary by (physician)

Dr.                           at phone #_                        or (Dentist) Dr.                            at phone #                          , or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child/ family member to (preferred hospital)                                                 or any other hospital reasonably accessible.

This authorization does not cover major surgery unless the medication opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Facts concerning the child’s/ family member’s medical history including allergies, medications being taken and any physical impairments to which a physician should be alerted:

Parent/Guardian Signature:                                                                              

Date                                             

PART II – REFUSAL TO CONSENT

I do not give my consent for emergency medical treatment for my child/ family member. In the event of illness or injury requiring emergency medical treatment, I wish the PLC authorities to take no action but to do the following:

Parent/Guardian Signature:                                                                              

Date