Emergency Treatment Consent Form printable pdf download

Emergency Treatment Consent Form

Child/Dependent's Name: ____________________________ ______Relationship:

______

Address: ___________________________City: _________________State :

Zip:

Home Phone: (_____)______________________Date of Birth:

Parent/Guardian:_______________________ Work Phone: ____________Cell phone:

Email of parent/guardian:

_______

Physician's Name:

Physician's Phone number__________

______

Emergency Contact (if listed parent/guardian unavailable)

Name:

Home Phone: ( ___)

_ Cell Phone: ( ___ )

___

Address:

________

_ City:

State: __

Zip:

_____

Relationship to child:

_______________

Work Phone (_____)______________________

Health Insurance Company:

Group Number:

ID Number :

Insured's Social Security number:

__________

"I hereby give my consent in advance to the designated leaders of SkyView Academy activities and field trips

and to the physicians or hospital selected by them to render emergency treatment as in their judgment is

reasonably necessary, including, but not limited to, hospitalization, diagnosis including taking specimens and

x-rays, giving blood transfusions and medications, anesthesia and surgery for my dependent listed above. I

understand that the leaders of this activity will attempt to contact me before securing medical treatment,

but that this consent is given in case I am not available in an emergency.

I specifically release the leadership of this activity as well as the leadership and members of SVA (SkyView

Academy Charter School) from any and all claims, loss, cost, damage or expense arising out of or from any

accident or other occurrences causing injury to any person or property."

Signature of Parent/Guardian

Date

Please return this form via fax at (303) 470-1903 or call (303)471-8439 with any questions.

SVA Emergency Treatment Consent

January 2011

Emergency Treatment Consent Form

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